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TREATMENT  OF 

MALOCCLUSION  OF  THE  TEETH 

AND 

FRACTURES  OF  THE  MAXILLE./ 
ANGLE'S  SYSTEM. 


Sixth   Edition,   Greatly   Enlarged   and   Entirely   Rewritten, 
With  Two  Hundred  and  Ninety-nine  Illustrations. 

BY 

EDWARD  H.  ANGLE,  M.D.,  D.D.S., 

Former    Professor   of  Histology,  Orthodontia,  and   Comparative  Anatomy  of  the  Teeth 
in  the   Dental  Department  of   the   University  of    Minnesota  ;  former  Professor  of 
Orthodontia  in  the  American  College  of  Dental  Surgery  and  in  the  North- 
western University  Dental  School,  Chicago,  111.,  and  in  the  Missouri 
Dental  College,    St.   Louis,  Mo.;  former   Surgeon  for  the 
Treatment  of  Fractures  of  the  Maxillre  to  the  Great 
Northern   R.    R.   and  to  the  Asbury 

Hospital,  Minneapolis,  Minn. 

President  of  the  Angle  School  of  Orthodontia,  St.  Louis,  Mo.  ;  Member  of  the  New 
York  Society  of  Stomatology  ;  Member  of  the  American  Dental  Associa- 
tion ;   Honorary  member  of  the  American  Dental  Society  of 
Europe  ;  Surgeon  for  the  Treatment  of  Fractures  of 
the  Maxillae  to  the  Wabash  R.   R. 


PHILADELPHIA: 
THE.S.  S.  WHITE  DENTAL  MANUFACTURING  COMPANY. 


Copyright,  1898,  by  EDWARD  H.  ANGLE. 
Copyright,  1900,  by  EDWARD  H.  ANGLE. 


Wo 

S 
tfffO 


To  all  those  who  have  been  perplexed  by  cases  of 
malocclusion  of  the  teeth  and  have  not  become  discouraged 
thereby,  but  rather  stimulated  to  a  keener  interest  in,  and  a 
broader  study  of,  this  most  beneficent,  fascinating,  and  pro- 
gressive branch  of  dental  science,  this  book  is  respectfully 
dedicated. 


PREFACE. 


THE  issuance  of  this  sixth  edition  of  this  work  in  its  enlarged 
form,  intended  by  the  author  as  a  culmination  of  his  labor  in  this 
line,  is  inspired  by  various  considerations.  The  system  of  appli- 
ances and  methods  of  treatment  introduced  in  the  former  editions 
have  been  well  received,  as  is  evidenced  by  the  number  of  editions 
issued  and  by  their  translation  into  the  French,  German,  Dutch, 
Scandinavian,  and  Spanish  languages  by  writers  in  the  countries 
where  these  languages  prevail.  As  a  result  of  busy  years  devoted 
to  teaching  and  the  exclusive  practice  of  orthodontia,  during 
which  the  science  has  been  an  absorbing  study  and  the  subject  of 
most  painstaking  investigation,  the  author  has  been  more  and 
more  impressed  with  its  far-reaching  importance  and  possibilities. 
He  is  actuated  in  the  present  instance  not  alone  by  the  earnest 
solicitation  of  teachers,  students,  and  practitioners,  but  also  by  an 
appreciation  of  the  necessities  of  this  science  and  the  hope  that  the 
principles  herein  recorded  may  be  instrumental  in  promoting  its 
advancement. 

The  subject  is  treated  far  more  comprehensively  in  this  edition 
than  in  those  which  have  preceded  it,  they  having  been  limited  to 
the  mechanical  phases  of  the  subject.  Much  of  this  early  matter 
has  been  rewritten,  some  of  it  being  eliminated — superseded  by 
better  methods,  the  object  always  being  to  keep  simplicity  and 
efficiency  foremost.  There  has  been  a  studied  effort  for  condensa- 
tion and  systematic  arrangement.  It  is  believed  that  lumbering 
volumes,  like  multiplicity  of  appliances  and  methods,  serve  rather 
to  leave  the  student  in  hazy  bewilderment  than  to  equip  him  for 
useful  practice.  On  the  other  hand,  a  mere  recital  of  the 
achievements  of  others,  by  divers  means,  without  system  or  de- 
tail, presupposes  a  knowledge  on  the  part  of  the  student  which  if 
possessed  would  render  the  slight  information  imparted  but  a 


yi  PREFACE. 

possible  matter  of  interest,  instead  of  a  necessity  of  study.  That 
this  work  will  be  found  radically  different  in  many  particulars  from 
the  usual  work  on  orthodontia  is  certain,  especially  in  that  many 
devices  for  regulating  the  teeth,  which  have  been  familiar  pictures 
from  the  earliest  remembrance  of  the  subject  of  our  oldest  practi- 
tioners, will  be  found  missing;  not  that  they  are  eliminated  on 
account  of  their  antiquity,  but  because,  analyzed  never  so  care- 
fully, they  fall  so  far  short  of  the  present  requirements  of  a  regula- 
ting appliance.  It  is  believed  that  instead  of  the  student  being 
longer  hampered  by  such  crudities,  they  are  entitled  to  only  such 
respect  as  by  right  awaits  them  in  history. 

It  has  long  been  the  effort  of  the  author  to  perfect  a  system 
which  should  be  complete  within  itself — a  system  which  should 
include  the  simplest  and  best  methods  not  only  for  the  treatment 
of  all  forms  of  malocclusion,  but  for  the  study  and  diagnosis  of 
cases,  as  well  as  for  the  teaching  of  the  subject  in  its  entirety. 
The  degree  of  his  success  must  be  determined  somewhat  by  time 
and  the  intelligent,  unbiased  judgment  of  others. 

In  the  illustrations,  which  are  all  original,  the  art  of  the  photog- 
rapher and  the  skill  of  the  engraver  have  been  severely  taxed  to 
accurately  represent  cases  from  actual  practice,  with  appliances 
and  methods  of  treatment  employed.  No  fanciful  pen-sketches 
of  imaginary  and  improbable  cases,  created  to  illuminate  theoreti- 
cal, complicated,  and  impractical  devices,  will  be  here  found.  The 
ideas  expressed  and  the  lines  of  practice  laid  down  are  also,  except 
as  is  otherwise  stated,  original  with  the  author,  and  he  accepts 
full  responsibility  for  them.  A  conscientious  effort  has  been  made 
to  give  proper  credit  for  all  inventions  of  acknowledged  merit. 
To  fair  minds  recorded  dates  are  usually  sufficient  evidence  of 
priority. 

This  work  is  designed  primarily  for  the  instruction  of  students 
in  colleges,  and  secondarily  as  a  guide  and  ready-reference-book 
for  practicing  dentists  who  have  not  devoted  special  study  to  the 
subjects  of  which  it  treats. 

It  has  been  said  that  "order  is  heaven's  first  law."  Order  im- 
plies exactness,  thoroughness.  Not  only  is  an  effort  made  to 
impress  these  principles  throughout  the  following  pages,  but  they 
have  prompted  the  manner  of  doing  it.  Literary  style  has  been 
subordinated  to  clearness  of  expression  and  precision  of  detail. 


PREFACE.  Vll 

This  may  explain  a  frequent  repetition  of  terms  and  methods  which 
would  be  inadmissible  in  a  narrative,  but  which  is  here  indulged 
for  the  convenience  of  the  student,  that  the  necessity  for  back- 
reference  may  be  reduced  to  the  minimum. 

A  poverty  of  terminology  has  long  been  felt  in  the  science  of 
orthodontia,  but  it  has  been  deemed  better  to  expand  the  meanings 
of  terms  employed,  in  many  instances,  to  meet  requirements  than 
to  increase  the  vocabulary  by  introduction  of  new  words.  Thus 
the  term  "malocclusion"  is  often  used,  for  convenience,  to  ex- 
press the  condition  of  malposition  of  a  tooth  which  has  no  occlu- 
sion at  all  with  other  teeth.  "Elevating"  is  a  term  employed  with 
similar  license.  We  may  speak  of  elevating  a  tooth  in  the  upper 
arch  when  we  really  pull  it  down,  and  so  with  other  usage  the 
meaning  of  which  should  be  clear. 

The  author  expresses  obligations  to  Professor  Black  for  some 
suggestions  in  regard  to  the  arrangement  of  the  subject-matter,  and 
to  Professor  Noyes  for  the  use  of  selections  from  his  valuable  col- 
lection of  microscopical  slides  of  the  peridental  membrane,  and  also 
for  actual  work  in  the  preparation  of  the  new  and  excellent  engrav- 
ings prepared  especially  for  this  work  to  illustrate  the  chapter  on 
the  peridental  membrane;  also  to  The  S.  S.  White  Dental  Mfg. 
Co.,  for  the  excellent  illustrations  which  they  have  cheerfully  pre- 
pared and  for  the  painstaking  thoroughness  of  their  work  as  pub- 
lishers. 


CONTENTS. 


^  PXCE 


INTRODUCTION i 

PART  L— ORTHODONTIA. 

CHAPTER  I. 

OCCLUSION  5 

Forces  Governing  Normal  Occlusion — Forces  Governing  Maloc- 
clusion — Line  of  Occlusion — Nomenclature. 

CHAPTER  II. 
FACIAL  ART. — LINE  OF  HARMONY 15 

CHAPTER  III. 

ETIOLOGY  OF  MALOCCLUSION 23 

Premature  Loss  of  Deciduous  Teeth — Prolonged  Retention  of  De- 
ciduous Teeth — Loss  of  Permanent  Teeth — Tardy  Eruption  of 
Permanent  Teeth — Supernumerary  Teeth — Habits — Disuse — 
Nasal  Obstructions — Abnormal  Frenum  Labium. 

CHAPTER  IV. 

CLASSIFICATION  AND  DIAGNOSIS  OF  MALOCCLUSION 34 

Class  I — Class  II,  its  Divisions  and  Subdivisions — Class  III  and  its 
Divisions. 

CHAPTER  V. 

ALVEOLUS  AND  PERIDENTAL  MEMBRANE 45 

CHAPTER  VI. 

MODELS — THEIR  CONSTRUCTION  AND  STUDY 57 

Material  for  Impressions — Method  of  Taking  Impressions — The 
Trays — Taking  and  Removing  the  Upper  Impression — Taking 
and  Removing  the  Lower  Impression — Pouring  and  Separating 
the  Model — Value  of  Good  Models — Photographs  of  Patients. 

CHAPTER  VII. 

REGULATING  APPLIANCES — PRELIMINARY  CONSIDERATIONS 67 

The  Old  and  the  New  Methods — Epochs  in  the  History — Requisite 
Qualifications  of  Appliances — Materials  for  Construction. 

CHAPTER  VIII. 

THE  AUTHOR'S  APPLIANCES 81 

General  Description  of — Tools  and  Instruments. 

CHAPTER  IX. 

SOLDERING  ^ 95 

Plain  Bands,  their  Construction  and  Attachments — Clamp  Bands  and 

their  Adjustment. 

ix 


X  CONTENTS. 

CHAPTER  X. 

PAGR 

ANCHORAGE 109 

Principles — Details. 

CHAPTER  XL 

COMBINATIONS  OF  APPLIANCES 1 16 

Jack-screw — Lever — Traction  Screw — Expansion  Arch,  its  History 
and  Combinations — Miscellaneous  Combinations. 

CHAPTER  XII. 

RETENTION    150 

Time  Required — Temporary  and  Permanent  Devices — Principles  and 
their  Application. 

CHAPTER  XIII. 

TISSUE  CHANGES  INCIDENT  TO  TOOTH  MOVEMENT 166 

Alveolus — Membrane — Pulp. 

CHAPTER  XIV. 

OPERATIVE  SURGERY 173 

Immediate  Movement — Alveolar  Section — Resection  of  Peridental 
Fibers — Section  of  Frenum  Labium — Double  Resection  of 
Maxilla. 

CHAPTER  XV. 

PHYSIOLOGICAL  CHANGES  SUBSEQUENT  TO  TOOTH  MOVEMENT 184 

CHAPTER  XVI. 

AGE  APPROPRIATE  FOR  TREATMENT 188 

Time  Required  for  Treatment. 

CHAPTER  XVII. 
TREATMENT    192 

Direction  of  Efforts — Correction  of  Malocclusion — Harmony  in  Rela- 
tions of  Jaws— Harmony  of  Facial  Lines — Treatment  of  Class  I. 

CHAPTER  XVIII. 

TREATMENT  OF  CASES. — CLASS  II,  DIVISION  i 234 

CHAPTER  XIX. 

TREATMENT  OF  CASES. — CLASS  II,  DIVISION  2 263 

CHAPTER  XX. 
TREATMENT  OF  CASES. — CLASS  III,  DIVISION 268 

CHAPTER  XXI. 
TECHNIQUE    280 

CHAPTER  XXII. 
GENERAL  SUGGESTIONS   281 


PART  II.— FRACTURES  OF  THE  MAXILLA. 
TREATMENT 285 


INTRODUCTION. 


MALOCCLUSION  of  the  teeth  is  found  in  all  races  and  even  oc- 
casionally among  the  lower  animals,  and  has  in  all  probability 
been  one  of  man's  afflictions  from  time  immemorial,  but  that  it  is 
becoming  more  common  as  civilization  progresses  is  very  generally 
agreed. 

The  real  growth  of  dentistry  is  of  comparatively  recent  years, 
and  along  lines  having  little  in  common  with  orthodontia,  so  that 
this  branch  received  little  attention  until  within  the  last  half-cen- 
tury, and  it  is  probable  that  more  real  interest  has  been  awakened 
and  more  real  advancement  made  in  the  last  thirteen  years  than  in 
its  entire  previous  history. 

Much  has  been  written  upon  the  subject  of  orthodontia,  and  its 
various  lines  have  been  quite  broadly  and  ably  studied.  It  has 
passed  through  marked  evolutionary  stages  to  its  development  as  a 
distinct  science,  the  broad  possibilities  of  which  are  even  yet  but 
dimly  comprehended  by  those  who  have  not  given  it  careful  study. 
In  the  light  of  our  present  knowledge  much  of  the  theory,  as  well 
as  of  the  practice,  of  even  a  few  years  ago  seems  strikingly  crude. 

Of  such  theory  and  practice  was  the  common  advice  to  young 
patients  to  "let  the  teeth  alone  and  trust  to  Nature  to  straighten 
them,"  or  to  wait  until  the  permanent  dentition  should  be  complete 
before  making  any  effort  toward  their  correction.  Of  such  was  the 
unfortunate  sacrifice  of  teeth  with  a  mistaken  view  of  relieving  the 
crowded  condition  of  the  arches,  but  with  the  result  often  of  ag- 
gravating the  malocclusion  and  giving  rise  to  a  serious  train  of 
evils,  as  shown  in  the  chapter  on  etiology.  So  also  the  use  of  huge 


2  MALOCCLUSION. 

plates  combined  with  springs  taken  from  clocks  and  various  strange 
mechanisms  as  a  means  of  tooth  movement,  which  now  seems 
more  in  accordance  with  many  of  the  teachings  of  medicine  during 
the  period  of  history  known  as  the  "dark  ages." 

Until  within  a  very  few  years  the  teaching  of  orthodontia  in 
dental  colleges  was  very  superficial,  even  ofttimes  being  wholly 
omitted  from  the  curriculum.  Now,  however,  in  some  of  our  col- 
leges separate  chairs  are  established  and  the  subject  is  far  more 
comprehensively  taught.  Yet  it  must  be  apparent  to  all  thoughtful 
observers  that  there  is  great  opportunity  for  further  improvement 
in  this  direction.  In  some  colleges  this  branch  of  the  science 
is  still  made  entirely  subservient  to  others,  notwithstanding  the 
fact  that  it  is  regarded  by  all  to  be  the  most  difficult  and  exacting 
of  any  of  the  branches  of  dentistry,  if  not  of  medicine.  In  fact,  so 
exacting  are  its  requirements,  both  in  teaching  and  in  practice,  that, 
unlike  the  general  practice  of  dentistry,  the  mere  smatterer  can 
never  hope  for  even  moderate  success,  for  often  apparently  very 
simple  cases  of  malocclusion  are  in  reality  only  symptoms  of  condi- 
tions whose  management  requires  the  broadest  knowledge  and 
mature  judgment. 

Orthodontia  is  a  subject  so  great,  so  important,  and  offering 
such  possibilities  and  rewards,  that  it  is  ample  in  itself  for  the  life- 
work  of  the  best  minds,  and  it  is  the  author's  firm  belief  that  it 
should  be  regarded  as  a  distinct  specialty,  and  that  it  should  be 
taught  and  practiced  as  such.  The  tendency  in  this  direction  is 
gratifying,  and  should  receive  encouragement  from  the  fact  that 
most  lines  of  science  are  rapidly  passing  into  those  of  specialties, 
with  far  more  rapid  progress  as  a  result.  Where  now  there  are 
but  two  or  three  specialists  in  the  world  who  give  their  entire 
time  to  orthodontia,  there  should  be  as  many  in  at  least  every  large 
city,  for  no  one  can  doubt  that  there  is  a  great  demand  for  such 
service. 

Every  dentist  who  is  endowed  with  a  natural  ingenuity  and  who 
is  studiously  devoted  to  his  profession  should  find  an  absorbing 


INTRODUCTION.  3 

interest  in  this  study.  His  adaptability  to  its  mastery  will  be  de- 
termined by  conscientious  application,  and  if  successful  his  efforts 
will  be  amply  rewarded.  He  will,  in  any  event,  find  gratification 
in  the  consciousness  that  he  will  have  deepened  his  conceptions 
of  the  science,  will  have  widened  the  scope  of  his  practice,  and  will 
at  least  have  avoided  many  of  the  disastrous  errors  now  common 
in  dental  practice.  The  importance,  however,  of  the  proper 
breadth  and  thoroughness  in  the  preparatory  study,  before  attempt- 
ing operations  in  orthodontia,  cannot  be  too  strongly  impressed. 

Malocclusion  of  the  teeth  has  become  so  common  that  it  is  now 
almost  the  rule,  rather  than  the  exception.  Go  where  we  will, 
wander  down  the  village  street  or  the  crowded  avenues  of  great 
cities,  in  churches  or  theaters,  or  wherever  humanity  congregates, 
and  we  will  be  confronted  by  these  deformities  in  such  numbers 
that  we  are  amazed  at  their  prevalence.  And  in  proportion  as 
malocclusion  exists  so  are  the  functions  of  the  teeth  and  speech  im- 
paired, and  the  facial  lines  marred.  The  opportunities  and  pos- 
sibilities of  improvement  of  the  features  by  proper  treatment  of  mal- 
occlusion are  so  great,  and  the  appreciation  of  the  patients  and 
their  friends  so  genuine  when  the  work  has  been  quickly  and 
intelligently  performed,  that  we  wonder  that  a  closer  study  and 
keener  interest  in  the  subject  by  practitioners  was  not  long  ago 
awakened,  and  are  surprised  that  so  few  have  any  conception  of 
the  possibilities  of  orthodontia  for  the  improvement  of  the  human 
face. 

Unfortunately  in  the  past, — and  still  to  a  large  extent, — the 
progress  of  orthodontia  has  been  seriously  handicapped  by  the 
apparent  belief  that  the  science  consisted  in  the  designing  and  con- 
structing of  regulating  appliances.  The  instructions  that  many 
students  still  receive  on  this  subject  would  seem  to  be  in  harmony 
with  this  belief.  In  reality  the  regulating  appliances  are  only 
secondary  to  many  more  important  considerations.  They  are  only 
a  means  to  an  end,  and  are  no  more  to  the  orthodontist  than  are  the 
colors  to  the  artist,  whose  success  depends  upon  the  breadth  of 


4  MALOCCLUSION. 

his  knowledge,  the  purity  of  his  conception,  and  his  skill  in  their 
use. 

It  is  not  enough  to  simply  move  into  correct  alignment  irregular 
teeth.  We  should  have  a  proper  conception  of  the  influence  of 
the  malocclusion  in  arresting  or  modifying  the  development  of 
the  alveolus,  jaws,  and  muscles,  and  in  shaping  the  contour  of  the 
face.  We  must  consider  the  numerous  possible  changes  which 
may  follow  the  movement  of  teeth  into  correct  positions,  with  the 
restoration  of  the  natural  functions  of  the  occlusal  planes,  and  the 
assistance  the  changes  will  lend  to  nature  as  they  stimulate  her  to 
efforts  for  the  continuation  of  normal  growth  and  development  of 
all  the  related  parts,  that  they  may  be  in  best  harmony  with  Nature's 
plan,  as  well  as  with  each  other  in  their  new  relations.  It  is  now 
well  known  that  the  structural  changes  which  follow  the  correction 
of  malocclusion  are  often  pronounced.  In  many  cases  there  can 
be  no  intelligent  diagnosis  or  plan  of  treatment  unless  the  change 
probabilities  be  fully  considered. 


PART  1. 


ORTHODONTIA. 


CHAPTER  I. 

OCCLUSION. 

THE  term  "irregularities  of  the  teeth,"  as  it  is  usually  applied 
to  express  the  condition  of  abnormal  arrangement,  does  not,  in  the 
author's  opinion,  properly  express  the  full  meaning  of  these  de- 
formities. It  would  seem  that  the  term  malocclusion  would  be  far 
more  expressive;  for  in  studying  the  subject  we  must  fully  ap- 
preciate the  importance  of  the  dental  apparatus  as  a  whole  and  the 
important  relations,  not  only  of  the  two  arches  to  each  other,  but 
of  each  individual  tooth  to  all  other  teeth  in  both  arches. 

The  shapes  of  the  cusps,  crowns,  roots,  and  even  the  very  struc- 
tural material  of  the  teeth  and  their  attachments,  are  all  designed 
for  the  purpose  of  making  occlusion  the  one  grand  object,  in 
order  that  they  may  best  serve  the  purpose  for  which  they  were 
intended, — namely,  the  cutting  and  grinding  of  food. 

Examined  carefully  it  will  be  seen  that  perfect  occlusion  is  in- 
compatible with  any  degree  of  irregularity,  but  that  the  arrange- 
ment of  the  teeth  must  be  even  and  regular,  each  contributing  sup- 
port to  the  others, — all  in  perfect  harmony.  Not  only  this,  but 
the  jaws,  the  muscles  of  mastication,  the  lips,  and  even  the  facial 
lines  will  then  be  in  best  harmony  with  the  peculiar  facial  type  of 
the  individual. 

Therefore,  we  should  be  constantly  impressed  with  the  impor- 
tance of  perfect  occlusion  in  the  study  and  treatment  of  these  de- 
formities, instead  of  making  occlusion  secondary,  or  even  losing 
sight  of  it  entirely,  as  has  been  too  much  the  practice  in  the  past. 

The  author  has  become  firmly  convinced  that  occlusion  is  the 

i 

5 


6  MALOCCLUSION. 

very  basis  of  the  science,  and  that  in  the  treatment  unless  occlusion 
be  established  the  results  will  be  largely  in  the  nature  of  failures, 
for  the  correction  of  malocclusion  is  but  the  establishing  of  har- 
mony of  the  occlusal  planes.  So  in  the  pages  that  are  to  follow 
he  will  make  occlusion  the  central  thought,  and  on  it  base  the 
classification  of  malocclusion,  as  well  as  the  nomenclature,  and  will 
define  orthodontia  (from  the  Greek  o>#«?,  straight,  oVW,9,  tooth) 
as  being  that  science  -which  Ms  for  its  object  the  correction  of  mal- 
occlusion of  the  teeth. 

Malocclusion  is  but  the  perversion  of  normal  occlusion,  and  in 
order  to  intelligently  comprehend  it  it  is  of  the  utmost  importance 
that  we  first  thoroughly  consider  normal  occlusion  and  the  princi- 
ples which  are  operative  in  establishing  and  maintaining  it. 

Occlusion,  as  the  basis  of  the  science  of  orthodontia,  is  the  stu- 
dent's most  important  lesson.  Its  proper  comprehension  pre- 
supposes a  knowledge  not  only  of  the  normal  relations  of  the 
occlusal  surfaces  of  both  permanent  and  deciduous  teeth,  but  of 
their  forms,  structure,  and  attachments,  their  growth  and  develop- 
ment, and  as  well  of  the  jaws  and  related  muscles.  His  perceptions 
of  the  subject  should  be  broadened  also  by  a  comparative  study  of 
the  occlusion  of  the  teeth  of  the  lower  animals.  The  limits  of  this 
work  will  not  permit  the  extended  consideration  of  these  funda- 
mental requisites,  for  which  the  student  is  referred  to  the  following 
excellent  works:  "Anatomy  and  Histology  of  the  Mouth  and 
Teeth,"  by  Professor  I.  N.  Broomell;  "Dental  Anatomy,"  by  Pro- 
fessor G.  V.  Black,  and  "Comparative  Anatomy  of  the  Jaws  and 
Teeth,"  by  Professor  A.  H.  Thompson. 

By  referring  to  Figs.  I  and  2,  which  represent  the  teeth  in  ideal 
normal  occlusion,  it  will  be  seen  that  each  dental  arch  describes  a 
graceful  curve,  and  that  the  teeth  in  these  arches  are  so  arranged  as 
to  be  in  greatest  harmony  with  their  fellows  in  the  same  arch,  as 
well  as  with  those  in  the  opposite  one. 

The  lower  arch  is  somewhat  smaller  than  the  upper,  so  that  in 
occlusion  the  labial  and  buccal  surfaces  of  the  teeth  of  the  upper 
jaw  slightly  overhang  those  of  the  lower. 

The  key  to  occlusion  is  the  relative  positions  of  the  first  molars. 
In  normal  occlusion  the  mesio-buccal  cusp  of  the  upper  first  molar 
is  received  in  the  buccal  groove  of  the  lower  first  molar;  the  teeth 
posterior  to  the  first  molars  engage  with  their  antagonists  in  a 


OCCLUSION. 


precisely  similar  way;  those  anterior  interlock  with  one  another  in 
the  interspaces  till  the  incisors  are  reached;  of  these  the  upper  over- 


E.H  A. 


FIG.  2. 


ZYGOMA 


hang  the  lower  about  one-third  the  length  of  their  crowns,  usually, 
though  the  length  of  the  overbite  varies,  being  greater  in  the  teeth 


8  MALOCCLUSION. 

indicating  the  bilious  and  nervous  temperaments,  and  less  in  the 
sanguineous  and  lymphatic  types. 

The  upper  central  being  broader  than  the  lower,  it  necessarily 
extends  beyond  it  distally,  overlapping  in  addition  about  one-half 
of  the  lower  lateral;  the  upper  lateral  occludes  with  the  remaining 
portion  of  this  tooth  and  with  the  mesial  incline  of  the  lower  cus- 
pid ;  the  mesial  incline  of  the  upper  cuspid  occludes  with  the  distal 
incline  of  the  lower  cuspid,  the  distal  incline  occluding  with  the 
mesial  incline  of  the  buccal  cusp  of  the  lower  first  bicuspid.  In 
the  same  order  the  series  of  buccal  cusps  of  the  bicuspids  occlude, — 
the  mesial  incline  of  each  occluding  with  the  distal  incline  of  the 
corresponding  lower  tooth. 

The  distal  incline  of  the  second  upper  bicuspid  occludes  with 
the  mesial  incline  of  the  mesial  cusp  of  the  lower  first  molar.  The 
mesial  incline  of  the  mesial  cusp  of  the  upper  first  molar  occludes 
with  the  distal  incline  of  the  mesial  cusp  of  the  lower  first  molar; 
the  distal  incline  of  the  mesial  cusp  of  the  upper  first  molar  oc- 
cluding with  the  mesial  incline  of  the  distal  cusp  of  the  lower  first 
molar;  the  mesial  incline  of  the  distal  cusp  of  the  upper  first  molar 
occludes  with  the  distal  incline  of  the  distal  cusp  of  the  lower  first 
molar,  the  distal  incline  of  this  cusp  occluding  with  the  mesial  in- 
cline of  the  mesial  cusp  of  the  lower  second  molar.  This  same 
order  is  continued  with  the  second  and  third  molars,  the  distal 
incline  of  the  distal  cusp  of  the  upper  third  molar  having  no  oc- 
clusion. 

It  will  thus  be  seen  that  each  of  the  teeth  in  both  jaws  has 
two  antagonists  or  supports  in  the  opposite  jaw,  except  the  lower 
central  and  the  upper  third  molar. 

As  the  inclined  planes  match  and  harmonize  most  perfectly  in 
the  bucco-occlusal  relations  of  the  teeth,  so  there  is  a  similar  ar- 
rangement in  the  linguo-occlusal  relations,  except  that  the  lingual 
cusps  of  the  lower  bicuspids  and  molars  project  beyond  the  upper 
into  the  oral  space. 

Likewise  in  the  transverse  arrangement,  the  buccal  cusps  of  the 
lower  molars  and  bicuspids  pass  between  the  buccal  and  lingual 
cusps  of  the  upper  molars  and  bicuspids,  and  the  lingual  cusps  of 
the  upper  molars  and  bicuspids  between  the  buccal  and  lingual 
cusps  of  the  lower  molars  and  bicuspids. 

The  grinding-surfaces  are  thus  enormously  increased  in  extent 


OCCLUSION.  9 

and  efficiency  over  what  would  be  possible  if  they  consisted  of  a 
single  row  of  cusps  or  of  plane  surfaces. 

But  increase  of  masticating-  surface  is  not  the  only,  perhaps  not 
even  the  most  important,  reason  for  this  complex  interdigitation 
of  the  cusps  and  inclined  planes  of  the  teeth,  but  its  main  office 
is  to  provide  for  the  teeth  a  mutual  support.  The  sizes,  forms,  in- 
terdigitating  surfaces,  and  positions  of  the  teeth  in  the  arches  are  such 
as  to  give  to  one  another,  singly  and  collectively,  the  greatest  possible 
support  in  all  directions. 

Forces  Governing  Normal  Occlusion. — An  important  part  played 
by  the  inclined  planes  of  the  cusps  is  in  influencing  the  direction 
of  the  teeth  while  erupting  and  taking  their  positions  in  the  arch. 
If,  however,  their  influence  be  perverted,  they  may  become  mis- 
chievous factors  in  the  production  of  malocclusion. 

When  the  teeth  first  emerge  from  the  gums  considerable  dis- 
placement is  often  noticeable,  but  this  need  occasion  no  uneasiness, 
provided  as  eruption  progresses  their  cusps  pass  into  the  normal 
influence  of  the  inclined  planes  of  the  opposing  cusps ;  but  once 
passed  beyond  the  normal  influence  into  the  abnormal  they  will 
not  only  be' deflected  from  their  proper  relations  in  the  arch,  but 
they  will  assist  in  the  displacement  of  the  opposing  teeth  as  well, 
and  oftentimes  of  those  which  are  to  follow  in  eruption.  So  there 
may  be  times  when  the  dividing  line  between  harmony  and  in- 
harmony  of  occlusion  is  very  slight.  Hence  the  importance  of 
careful  attention  during  the  important  period  covering  the  erup- 
tion of  the  permanent  teeth,  especially  the  beginnings. 

Harmony  between  the  upper  and  lower  arches  and  their  teeth  is 
also  powerfully  promoted  by  their  normal  action  and  reaction 
upon  each  other.  As  the  teeth  of  the  lower  arch  erupt  before  those 
of  the  upper,  and  are  consequently  to  an  extent  fixed  in  their  posi- 
tions before  their  antagonists  appear,  it  follows  that  the  lower  arch 
is  the  form  over  which  the  upper  is  molded.  In  other  words,  the 
lower  arch  exerts  a  controlling  influence  over  the  form  of  the  upper 
and  the  positions  of  the  teeth  therein.  Of  course,  the  upper  re- 
acts upon  the  lower,  but  it  is  unquestionable,  in  the  author's 
opinion,  that  the  lower  arch  is  the  more  important  factor,  not 
the  upper,  as  has  hitherto  been  taught. 

It  will  thus  be  readily  seen  how  greatly  one  arch  contributes  to 
the  other  in  maintaining  its  form  and  size,  so  that  pressure,  as  for 


IO  MALOCCLUSION. 

example  on  the  labial  surfaces  of  the  upper  incisors,  would  be 
resisted  not  only  by  all  the  upper  teeth  acting  as  blocks  of  stone 
in  an  arch  of  masonry,  but  also  by  the  teeth  of  the  lower  arch  acting 
through  occlusion. 

Inversely,  then,  one  arch  cannot  be  altered  in  shape  without 
modifying  that  of  the  other,  nor  can  it  be  altered  in  size  without 
soon  exercising  a  marked  effect  on  the  other. 

This  important  fact  is  of  the  greatest  interest  to  us  as  students 
of  orthodontia, — namely,  that  in  a  case  of  perfect  occlusion,  as  in 
the  illustrative  case  shown,  each  tooth  is  not  only  in  perfect  har- 
mony with  every  other,  but  helps  to  maintain  it  in  its  harmonious 
relations,  for  the  cusps  interlock  and  each  sloping  plane  serves  to  not 
only  keep  the  tooth  in  position,  but  to  prevent  it  from  sliding  out,  and 
to  wedge  it  into  position  if  slightly  malposed,  that  is  if  not  beyond 
the  normal  influence  of  the  inclined  planes. 

A  careful  study  of  the  relations  of  the  inclined  planes  and  the 
marginal,  triangular,  and  oblique  ridges,  in  connection  with  the 
movements  of  the  jaw,  cannot  fail  to  impress  thoughtful  persons 
not  only  with  the  influence  which  these  exert  in  maintaining  each 
individual  tooth  in  correct  position,  but  as  well  their  wonderful 
efficiency  for  incising  and  triturating  the  omnivorous  food  re- 
quired by  man,  and  with  their  marvelous  arrangement  for  self- 
cleansing  and  consequent  self-preservation. 

Harmony  in  the  sizes  and  relations -of  the  arches  is  further  as- 
sisted by  another  force,  namely  muscular  pressure,  the  tongue  act- 
ing upon  the  inside,  and  the  lips  and  cheeks  upon  the  outside  of 
the  arches.  The  latter,  if  normal  in  development  and  function, 
serve  to  keep  the  arches  from  spreading,  as  do  hoops  upon  the 
staves  of  a  cask;  the  former  prevents  too  great  encroachment  upon 
the  oral  space.  I  am  satisfied  that  this  muscular  pressure  is  a  far 
more  important  factor  than  is  generally  recognized. 

So  it  will  be  seen  that  the  occlusion  of  the  teeth  is  maintained, — 
first,  by  the  occlusal  inclined  planes  of  the  cusps;  second,  by  the 
support  given  by  the  interdependence  of  the  arches  due  to  their 
harmony  in  sizes  when  in  normal  relations;  third,  by  the  influence 
of  the  muscles  labially,  buccally,  and  lingually.  The  illustrations 
show  the  result  where  these  forces  have  acted  normally, — a  har- 
moniously aligned  and  occluded  denture. 

Forces  Governing  Malocclusion. — These  forces   not  only   con- 


OCCLUSION. 


II 


tribute  to  maintaining  the  teeth  in  their  normal  positions  and 
to  harmony  in  the  sizes  of  the  normal  arches,  but  they  are  equally 
powerful  in  maintaining  inharmony  in  the  sizes  or  relations  of  the 
arches  and  malocclusion  of  the  teeth,  when  once  established.  In  a 
large  percentage  of  cases  of  malocclusion  the  arches,  are  more  or 
less  contracted,  and  as  a  result  we  find  the  teeth  crowded,  bunched, 
and  overlapping,  or,  as  crudely  designated  by  one  author, 
"jumbled."  In  these  cases  the  lips  serve  as  constant  and  powerful 
factors  in  maintaining  this  condition,  usually  acting  with  equal 
effect  on  both  arches,  and  effectually  combating  any  influence  of 
the  tongue  or  any  inherent  tendency  on  the  part  of  Nature  toward 
self-correction.  In  other  words,  the  narrow  and  diminished  sizes 

FIG.  3. 


of  the  arches  are  fixed,  and  they  are  prevented  from  enlarging  by 
the  lips  with  a  force  equal  in  power  to  that  exerted  when  the  arches 
are  of  normal  size  and  the  teeth  in  normal  occlusion.  Likewise, 
each  inclined  plane  of  the  cusps  out  of  harmony  in  the  occlusion 
serves  to  maintain  it  in  its  malposition,  or  to  wedge  it  still  farther 
out  of  position,  upon  each  closure  of  the  jaw.  It  is  interesting  and 
instructive  to  note  the  result  of  these  forces  even  in  the  earliest  in- 
dications of  malocclusion. 

Fig.  3  illustrates  a  developing  form  of  malocclusion,  very  com- 
mon and  familiar  to  all  observing  dentists.  The  case  is  that  of 
a  child  where  the  four  lower  permanent  incisors  are  fully  erupted, 
but  one  of  them  (the  left  lateral)  has  been  deflected  lingually,  Fig.  4. 
The  arches  being  thus  deprived  of  the  wedging  and  retaining  in- 


12  MALOCCLUSION. 

fluence  of  this  tooth,  the  external  pressure  of  the  lips  has  closed 
the  space  and  diminished  the  size  of  the  arch.  At  the  same  time 
pressure  of  the  lips  and  cheeks  (aided  by  the  occlusal  planes)  is 
gradually  molding  the  upper  arch  to  conform  to  the  abnormal  size 
of  the  lower. 

It  will  thus  be  seen  how  effectually  the  maintenance  of  the  mal- 
occlusion  has  been  provided  for,  and  how  hopeless  it  is  to  expect 
Nature  to  correct  this  deformity  unaided.  As  well  might  we  ex- 
pect the  self-cure  of  strabismus  of  the  eye  or  curvature  of  the  spine. 
How  absurd,  even  pernicious,  then,  is  the  common  advice  of  many 

FIG.  4. 


dentists  to  parents  to  "Let  Nature  alone  and  the  teeth  will 
straighten  themselves."  These  same  influences  may  be  traced  in  a 
similar  manner  in  any  case  of  malocclusion. 

Recognizing  the  potency  of  these  influences  it  must  be  apparent 
to  every  thoughtful  observer  that  cases  of  this  kind,  instead  of 
being  self-corrective,  will  become  more  and  more  complicated  as 
time  goes  on  and  as  each  succeeding  permanent  tooth  shall  be 
erupted.  In  all  such  cases  the  positions  of  the  incoming  perma- 
nent lower  incisors  should  be  guarded  with  zealous  care,  and  should 
be  maintained  by  corrective  procedure  if  necessary.  Then,  unless 
there  be  unusual  influences  or  tendencies  toward  malocclusion,  the 
positions  of  the  teeth  in  the  upper  arch  will  be  directed  normally. 

On  the  other  hand,  for  the  reason  previously  stated,  if  the  teeth 
of  the  lower  arch  be  permitted  to  remain  in  malposition  even  to 
the  slightest  overlapping  of  one  or  more  of  the  incisors  or  cuspids, 


OCCLUSION.  13 

the  normal  size  of  the  arch  will  be  diminished  to  that  extent,  with 
a  corresponding  contraction  of  the  size  of  the  upper  arch  and  some 
form  of  bunching,  as  a  result  of  the  influence  of  the  lips. 

So  we  can  with  much  confidence,  by  examining  a  model  of 
either  the  upper  or  lower  arches  of  a  case  belonging  to  Class  1 
of  malocclusion,  determine  the  extent  of  malocclusion  in  the  op- 
posite arch.  The  length  of  overbite  of  the  teeth  in  the  upper  arch 
will,  of  course,  modify  this  rule,  though  but  slightly.  The  con- 
forming of  one  arch  to  the  other  seems  to  be  Nature's  plan  of 
patching  up  her  deformities  in  order  to  render  the  teeth  as  efficient 
as  possible,  even  in  malocclusion.  If  the  reader  will  turn  to  the 
figures  illustrating  Class  II,  Division  2,  and  Class  II,  Division  2, 
Subdivision,  he  will  find  even  more  striking  illustrations  of  the  in- 
fluence of  the  muscles  in  molding  the  upper  arch  to  conform  to  the 
lower. 

Finally,  recognizing  the  influence  of  the  muscles  and  of  the  in- 
clined planes  of  the  teeth  in  establishing  and  maintaining  harmony 
in  the  sizes  and  relations  of  the  arches  and  in  the  occlusion  of  the 
teeth,  the  folly  of  correcting  the  malpositions  of  the  teeth  in  the 
upper  arch  alone  without  equal  attention  to  those  of  the  lower,  as 
is  so  often  done,  becomes  apparent. 

Line  of  Occlusion. — When  the  teeth  are  in  normal  occlusion 
their  greatest  number  of  points  of  contact  will  be  found  to  lie  along 
an  imaginary  line  passing  over  the  points  of  the  buccal  cusps  of  the 
molars  and  bicuspids,  and  the  cutting-edges  of  the  cuspids  and 
incisors  of  the  lower  arch,  and  along  the  sulcus  between  the  buccal 
and  lingual  cusps  of  the  upper  molars  and  bicuspids,  thence  for- 
ward, crossing  the  lingual  ridge  of  the  cuspids  and  the  marginal 
ridges  of  the  incisors  at  a  point  about  one-third  the  length  of  their 
crowns  from  their  cutting-edges.  This  we  shall  call  the  Line  of 
Occlusion,  and  will  define  it  as  being  the  line  of  greatest  normal 
occlusal  contact. 

This  line  describes  more  or  less  of  a  parabolic  curve,  and  varies 
somewhat  within  the  limits  of  the  normal,  according  to  the  race, 
type,  temperament,  etc.,  of  the  individual,  therefore  the  normal 
form  of  this  line  must  be  determined  in  any  given  case  by  the  judg- 
ment of  the  operator  after  a  careful  study  of  the  features,  facial 
lines,  forms  of  teeth  as  related  to  temperament,  etc. 

In  the  diagnosis  of  cases  it  is  important  that  we  should  have 


14  MALOCCLUSION. 

this  definite  line  as  a  more  accurate  base  from  which  to  reason 
and  note  variations  than  the  less  definite  outline  as  indicated  by  the 
incisive  and  occlusal  ends  of  the  teeth. 

All  teeth  found  out  of  harmony  with  the  line  of  occlusion  may 
be  sard  to  occupy  positions  of  malocclusion,  and  each  tooth  may 
occupy  any  of  seven  malpositions  or  their  various  deviations  and 
combinations. 

The  malpositions  of  teeth  consist  principally  in  the  variation 
from  the  normal  of  the  positions  of  their  crowns,  with  usually 
little  displacement  of  the  apices  of  their  roots,  so  that  they  incline 
at  an  angle  more  or  less  oblique  from  the  normal.  In  some  in- 
stances, however,  there  is  some  displacement  of  the  apices  as  well 
as  of  the  crowns,  they  having  either  developed  in  malpositions,  or 
having,  as  in  most  instances,  been  forced  from  their  normal  posi- 
tions by  the  eruption  of  more  powerful  teeth  in  juxtaposition,  as 
for  example  the  crowding  lingually  of  the  lateral  incisors  by  the 
development  and  eruption  of  the  cuspids,  as  in  Fig.  210.  Yet 
even  in  such  cases  the  displacement  of  the  apices  is  more  apparent 
than  real,  the  marked  malpositions  which  the  crowns  occupy  lend- 
ing to  the  appearance  of  displacement  of  the  points  of  their  roots. 

Nomenclature. — A  definite  nomenclature  is  as  necessary  in 
orthodontia  as  in  anatomy.  The  coarse  outlines  and  mere  phrases 
heretofore  often  used  are  totally  inadequate.  The  terms  for  de- 
scribing the  various  malpositions  should  be  so  precise  as  to  con- 
vey at  once  a  clear  idea  of  the  nature  of  the  malocclusion  to  be 
corrected.  The  author  therefore  suggests  the  following,  which, 
while  perhaps  not  perfect,  still  seems  to  be  a  great  improvement 
over  present  usage. 

For  example,  a  tooth  outside  the  line  of  occlusion  may  be  said 
to  be  in  buccal  occlusion;  when  inside  this  line,  in  lingual  occlu- 
sion; if  farther  forward,  or  mesial,  than  normal,  in  mesial  occlusion; 
if  in  the  opposite  direction,  in  distal  occlusion;  if  turned  on  its 
axis  it  would  be  in  torso-occlusion.  Teeth  not  sufficiently  ele- 
vated in  their  sockets  would  be  in  infra-occlusion,  and  those  that 
occupy  positions  of  too  great  elevation  would  be  in  supra-occlu- 
sion. 

These  different  malpositions,  in  their  modifications  and  com- 
binations, form  the  basis  for  limitless  variations  of  occlusion  from 
the  normal,  from  the  simplest  to  the  most  complex,  in  which  may 


FACIAL    ART. — LINE   OF    HARMONY.  15 

be  involved  not  only  the  malpositions  of  all  the  teeth,  but  even  the 
relations  of  the  jaws,  resulting  in  marked  deformities  and  produc- 
ing appearances  even  repulsive. 

In  order  to  better  comprehend  the  varying  peculiarities  of  cases 
of  malocclusion  it  will  be  necessary  to  consider  another  important 
phase  of  the  subject, — namely,  the  relation  of  the  features  to  the 
occlusion  of  the  teeth. 


CHAPTER   II. 

FACIAL   ART. — LINE    OF   HARMONY. 

ONE  of  the  evil  effects  of  malocclusion  is  the  marring  or  dis- 
torting of  the  normal  facial  lines.  It  follows  that,  in  the  applica- 
tion of  the  principles  of  orthodontia,  our  efforts  should  be  so 
directed  as  to  mold  and  modify  these  lines  of  inharmony  to  those 
of  harmony  and  facial  beauty  so  far  as  lies  within  the  range  of  the 
possibilities  of  art,  and  of  the  type  and  temperament  of  the  indi- 
vidual. Our  opportunities  for  benefiting  humanity  are  very  great 
in  this  field,  far  exceeding  those  offered  by  any  other  branch  oi 
dental  science,  for  patients  with  facial  lines  so  distorted  as  some- 
times to  be  a  marked  deformity  and  a  source  of  constant  humilia- 
tion to  themselves  and  their  friends  may  now  be  so  treated  as  to 
bring  about  a  complete  transformation  of  the  facial  expression, 
even  to  the  establishment  of  lines  of  beauty.  But,  lacking  a  proper 
appreciation  of  the  true  purpose  of  orthodontia,  we  may  work  in 
such  utter  ignorance  of  the  requirements  of  facial  art,  as  is  often 
done,  as  to  not  only  fail  to  improve  the  appearance,  but  even  to 
produce  results  still  more  unpleasing  than  the  original  condition. 

In  order  to  work  intelligently  it  is  important  that  we  shall  have 
first  fixed  in  our  minds  the-  outlines  of  the  perfect  face,  so  that 
we  may  ever  have  an  ideal  which,  like  teeth  in  normal  occlusion, 
shall  serve  as  a  pattern  from  which  to  note  deviations  and  to  guide 
us  in  our  efforts  toward  the  establishment  of  the  normal. 

For  this  perfect  face  we  shall  look  in  vain  among  the  people 
we  meet.  Although  we  may  find  many  having  more  or  less  of 
the  characteristics  of  beauty,  all  will  be  found  to  possess  one  or 
more  lines  not  in  harmony  with  the  ideal  face. 


1 6  MALOCCLUSION. 

Raphael,  the  great  artist,  said,  "There  is  nothing  so  rare  as 
perfect  beauty  in  women."*  When  painting  the  head  of  Galatea, 
he  was  unable  to  find  in  the  faces  of  the  living  a  sufficiently  perfect 
type  of  beauty  to  serve  as  his  model,  and  was  compelled  to  substi- 
tute for  nature  a  certain  ideal  inspired  by  his  fancy. 

In  proceeding  to  define  beauty,  all  that  the  writers  on  art  have 
been  able  to  do  is  to  affirm  the  expression  of  Albrecht  Durer,  that 
"beauty  is  the  reverse  of  deformity.  The  more  remote  from  de- 
formity, the  nearer  the  approach  to  beauty." 

We  must  have  recourse,  then,  to  the  purely  ideal, — to  suggest, 
to  guide,  to  vary  in  imitation,  but  never  to  rigidly  copy.  "A 
profile  well  chosen,  all  the  features  will  be  made  to  harmonize  with 
it;  and  according  to  the  profile  will  correspond  in  form  the  beauty 
of  all  the  other  features.  No  face  was  ever  repulsive  where  the 
profile  was  beautiful,  and  no  face  can  be  made  beautiful  while  the 
profile  is  ugly." 

Fig.  5  represents  the  profile  of  a  face  so  perfect  in  outline  that 
it  has  long  been  the  model  for  students  of  facial  art.  It  is  that  of 
Apollo,  one  of  the  Grecian  mythological  gods.  It  is  supposed 
to  be  so  faultless  in  form  that  to  change  it  in  the  least  would  be  to 
mar  the  wonderful  harmony  of  proportions ;  as  Fuseli  puts  it, 
"Shorten  the  nose  by  but  the  tenth  of  an  inch  and  the  god  would 
be  destroyed." 

All  the  essentials  of  beauty  found  in  this  face  can  be  traced  with 
but  minute  variations  in  all  other  masterpieces  of  art  representing 
ideal  facial  beauty,  as  the  Psyche,  Sistine  Madonna,  Medusa,  Venus 
de  Milo,  etc.,  and  consist  in  a  short,  finely  curved,  and  prominent 
upper  lip;  a  full,  round,  but  less  prominent,  lower  lip,  with  a 
strongly  marked  depression  at  its  base,  giving  roundness  and 
character  to  the  chin.  These  characteristics  of  the  lower  part  of 
the  face  are  'elements"  of  beauty  wherever  found,  regardless  of 
race,  type,  or  temperament.  At  the  present  day  the  pure  Greek 
type  is  rarely  seen,  but  we  nevertheless  do  see  in  all  handsome 
profiles  very  much  the  same  outline  in  the  lower  part  of  the  face 
as  has  been  indicated,  the  variations  being  in  the  upper  half  of 
the  face  and  not  in  the  lower.  In  studying  the  perfection  of  the 
profile  it  will  be  seen  that  it  is  in  perfect  harmony  with  a  straight 
line  at  three  points, — namely,  the  most  prominent  points  of  the 
*Bell's  Anatomy  of  Facial  Expression. 


FACIAL    ART. LINE    OF    HARMONY.  l"J 

frontal  and  mental  eminences  and  the  middle   of  the  ala  of  the 
nose. 

As  a  convenience  we  shall  call  this  the  line  of  harmony.  It 
will  be  found  of  great  value  as  a  basis  of  diagnosis,  serving  the 
same  purpose  in  the  esthetics  of  the  face  as  does  the  line  of  occlu- 
sion in  indicating  the  variations  of  the  teeth  from  the  normal 
alignment. 

FIG.  5. 


Fig.  6*  shows  the  application  of  this  line  to  another  face  of  much 
beauty,  which,  it  will  be  seen,  is  in  harmony  at  the  three  points 
above  indicated. 

Fig.  7*  shows  still  another  very  beautiful  face,  in  which  it  is 
easy  to  note  how  nearly  the  line  of  harmony  approaches  the  ideal ; 
while  Fig.  8  shows  another  face  in  many  respects  quite  perfect, 

*Copyright,  Morrison,   Chicago. 
3 


i8 


MALOCCLUSION. 

FIG.  6. 


FIG.  7. 


FACIAL   ART. LINE   OF    HARMONY. 

FlG.   8. 


FIG.  9. 


20 


MALOCCLUSION. 


but  when  measured  by  the  line  of  harmony  we  may  quickly  detect 
its  variations  from  the  ideal  and  the  consequent  unpleasing  effect. 
Fig.  9  shows  the  profile  of  still  another  face  in  which  the  variation 
from  the  line  of  harmony  is  very  great,  and  the  result  a  real  de- 
formity. 

As  we  readily  find  that  any  variation  in  any  region  of  the  profile 
may  be  easily  detected  upon  application  of  this  line,  we  will  apply 
the  terms  pro-  or  sub-,  according  to  development  and  location,  to 
designate  these  variations,  as  for  example  sub-intermaxillary,  de- 

FIG.  10. 


noting  an  arrested  development  in  the  region  of  the  intermaxillary 
bones;  or  pro-intermaxillary,  to  describe  the  opposite,  or  exces- 
sive development:  pro-inferior  maxillary  and  sub-inferior  maxil- 
lary, to  designate  excessive  or  deficient  development  or  protrusion 
or  retrusion  of  the  maxilla ;  or  pro-mental  and  sub-mental  develop- 
ment, to  denote  excess  or  deficiency  in  the  development  of  the 
chin;  or  pro-  and  sub-dental,  to  denote  the  excessive  inclination 
outward  or  inward  of  the  incisors,  etc.  In  like  manner  prominence 
or  deficiency  in  the  development  of  the  lips  may  be  indicated. 
Fig.  10  illustrates  sub-mental  development ;  Fig.  1 1  illustrates  pro- 
labial  and  sub-mental  development. 

These  terms  seem  to  the  author  to  far  more  nearly  meet  our 


FACIAL    ART. LINE    OF    HARMONY. 


21 


requirements  than  the  very  limited  and  commonly  employed  terms, 
prognathism  and  orthognathism,  which  were  introduced  by  the 
craniologist  for  describing  the  variation  of  the  facio-cranial  angle  of 
man  and  the  lower  animals,  but  which  are  wholly  inadequate  for 
expressing  the  variations  caused  by  malocclusion  of  the  teeth  and 
asymmetrical  development  of  the  bones  and  muscles  of  the  face. 

FIG.  ii. 


Judgment  and  practice  are  necessary  in  making  use  of  this  line 
in  order  not  to  mistake  the  mal-condition  of  one  region  for  that 
of  another.  As  for  example  in  that  class  of  cases  of  malocclusion 
represented  by  Fig.  12,  the  mistake  is  commonly  made  of  supposing 
it  to  be  pro-intermaxillary  development,  while  in  reality  the  devel- 
opment is,  in  nearly  every  case,  sub-inferior  maxillary,  as  is  proven 
by  Fig.  13,  which  represents  the  same  face  after  treatment.  This 
consisted  principally  in  sliding  the  lower  jaw  forward  to  obtain 
normal  occlusion  of  the  teeth,  which  was  made  possible  by  first 
establishing  harmony  in  the  line  of  occlusion,  as  described  under 


22 


MALOCCLUSION. 


treatment  of  cases  of  malocclusion  belonging  to  Class  II,  Divi- 
sion i. 

FIG.  12. 


FIG.  13. 


All  who  hope  to  attain  real  success  in  the  correction  of  malocclu- 
sion should  cultivate  a  love  for  art  and  the  beautiful,  and  form  the 
habit  of  observing  and  carefully  studying  the  normal  and  abnormal 
lines  of  the  human  face,  together  with  their  relations  to  and  de- 
pendence upon  the  occlusion  of  the  teeth.  An  appreciation  and 


ETIOLOGY    OF    MALOCCLUSION.  23 

intelligent  application  of  the  principles  of  art  must  ever  go  hand 
in  hand  with  the  successful  practice  of  orthodontia. 

The  ease  and  certainty  with  which  teeth  are  now  moved  by 
means  of  modern  regulating  appliances  has  opened  up  great  possi- 
bilities in  this  field  of  facial  art,  and  there  can  no  longer  be  just 
excuse  for  ignoring  this  most  important  phase  of  the  subject. 


CHAPTER    III. 

ETIOLOGY    OF    MALOCCLUSIOX. 

THE  causes  which  are  operative  in  producing  malocclusion, 
many  of  which  are  as  yet  imperfectly  understood,  are  usually 
divided  into  inherited  and  acquired. 

Interesting  and  common  observations  of  every  one  are  inherited 
peculiarities  of  children,  such  as  voice,  gestures,  gait,  traits  of 
character,  etc.,  and,  of  special  significance  to  us,  peculiarities  in 
the  form,  structure,  or  arrangement  of  the  teeth  which  are  often 
striking.  A  misshapen  central  or  cone-shaped  lateral  of,  diminu- 
tive size  has  been  frequently  traced  through  several  generations. 
So  may  the  arrangement  of  the  teeth  in  the  arches,  like  the  family 
likeness  in  faces,  be  traced  to  the  father,  mother,  or  grandparents, 
and  doubtless  often  to  remote  ancestors.  It  is  the  author's  ob- 
servation that  when  malocclusion  is  inherited  the  deformity  is  often 
intensified  in  the  patient. 

The  intermarriage  of  different  races  is  commonly  regarded  as  a 
prolific  cause  of  malocclusion  of  the  teeth,  especially  if  the  parents 
present  marked  differences  physically  or  mentally,  the  supposed 
effect  being  the  inharmonious  development  of  the  offspring,  with 
malocclusion  of  the  teeth  as  one  of  the  results.  For  example,  if 
one  of  the  parents  has  large  jaws  and  large  teeth,  while  the  other 
has  small  jaws  and  small  teeth,  the  child  might  inherit  large  teeth 
from  one  and  small  jaws  from  the  other,  the  result  being  necessa- 
rily a  crowded  and  malarranged  condition  of  the  teeth.  But  this 
possibility,  though  seemingly  plausible  in  theory,  is  open  to  seri- 
ous doubts  to  all  students  who  study  the  question  carefully,  as 
Nature's  plan  is  to  harmonize  the  proportions  of  the  anatomy. 

It  is,  however,  a  well-known  fact  that  many  children,  while  in- 


24  MALOCCLUSION. 

heriting  no  direct  peculiarities  of  the  teeth  or  jaws,  yet  receive 
by  transmission  tendencies  to  physical  degeneracy  which  may  be 
manifested  in  irregularities  of  the  teeth  and  asymmetrical  develop- 
ment of  the  jaws,  as  well  as  in  derangements  of  other  parts  of  the 
anatomy. 

But  far  more  numerous  are  the  causes  which  are  operative  after 
birth,  which  act  mechanically,  and  which  are  principally  local. 

Premature  Loss  of  Deciduous  Teeth. — Nature  has  designed 
for  the  deciduous  teeth  not  only  the  important  function  of 
masticating  the  food  required  by  the  child  up  to  the  period  of  their 
normal  loss  and  their  replacement  by  the  succeeding -permanent 
teeth,  but  also  that  of  assisting  in  a  mechanical  way  in  the  develop- 
ment of  the  alveolar  process,  and  as  well,  probably,  the  develop- 
ment of  the  jaw. 

The  permanent  teeth  being  larger  and  more  numerous  than  the 
deciduous,  the  greater  space  required  by  them  is  provided  prin- 
cipally by  the  lengthening  of  the  lateral  halves  of  the  dental  arches. 
This  is  influenced  largely  by  the  development  and  eruption  of  the 
permanent  molars  posterior  to  the  deciduous  molars.  If  the 
mesio-distal  diameters  of  the  deciduous  teeth  be  not  impaired  by 
caries  and  the  teeth  remain  the  normal  period,  the  first  permanent 
molar  in  taking  its  position  in  the  arch  must  force  its  way  between 
the  second  deciduous  molar  and  the  ramus  of  the  jaw  if  below,  or 
the  maxillary  tuberosity  if  above. 

Coincident  with  the  development  of  the  jaw  the  deciduous  teeth 
are  carried  forward,  and  the  normal  mesio-distal  lengthening  of 
the  process  takes  place.  If,  however,  one  of  the  deciduous  teeth 
be  prematurely  lost,  as  for  example  the  lower  first  molar,  the  in- 
coming permanent  molar  will  exert  its  wedging  influence  only 
distally  to  the  lost  tooth ;  it  will  occupy  a  portion  of  the  space,  and 
will  not  cause  any  forward  movement  of  the  anterior  teeth.  If, 
meanwhile,  no  teeth  have  been  lost  in  the  same  side  of  the  oppos- 
ing arch  the  wedging  process  will  have  pushed  forward  the  decid- 
uous teeth  and  the  normal  development  will  have  occurred.  There 
will  thus  be  an  inequality  between  the  jaws  on  the  affected  side, 
with  the  establishment  of  malocclusion.  And  this  is  not  the  only 
evil,  for,  the  space  occupied  by  the  lost  tooth  having  been  closed 
or  greatly  diminished,  the  eruption  of  the  succeeding  permanent 
tooth  (first  bicuspid)  will  be  prevented  entirely,  or  it  will  be  forced 


ETIOLOGY    OF    MALOCCLUSION.  25 

into  buccal  or  possibly  lingual  occlusion,  as  in  Fig.  131.  The 
shortened  lateral  half  will  not  develop  and  the  lower  arch  will  con- 
sequently be  smaller  than  normal,  which  must  result  in  protrusion 
of  the  upper  incisors  by  the  lower  lip  being  forced  beneath  them, 
or,  as  we  have  already  noted,  in  an  irregular  arrangement  of  the 
teeth  in  the  upper  arch  through  the  effort  of  Nature  to  restore 
harmony  in  the  sizes  of  the  two  arches  by  lip  pressure. 

A  similar  result  from  the  premature  loss  of  the  deciduous  cuspid 
may  be  seen  in  Fig.  273 ;  also,  of  the  incisors  and  cuspids,  Figs. 
206  and  208.  While  probably  the  greatest  harm  results  from  the 
premature  loss  of  the  second  deciduous  molar  or  cuspid  in  either 
arch,  yet  the  principle  applies  to  the  loss  of  any  of  the  deciduous 
teeth,  the  difference  being  only  in  degree.  This  is  only  another 
lesson  in  occlusion.  Rare  instances  have  been  reported  where  no 
evil  effects  have  followed  the  premature  loss  of  deciduous  teeth, 
especially  the  upper  incisors  and  cuspids,  yet  this  not  only  indi- 
cates that  in  those  cases  there  was  unusually  good  natural  develop- 
ment of  the  jaw,  but  proves  the  absence  of  any  unfavorable  tenden- 
cies, either  acquired  or  inherited.  Had  there  been  any  such 
tendency,  in  all  probability  malocclusion  would  have  resulted. 

The  mechanical  influence  of  the  deciduous  teeth  in  the  develop- 
ment of  the  dental  arches  is  so  important  that  they  should  not  only 
by  all  means  be  retained  their  full  normal  period,  but  if  they  be- 
come  affected  by  caries  their  full  mesio-distal  diameters  should 
be  restored  by  suitable  fillings  after  sufficient  separation. 

Likewise,  if  a  deciduous  tooth  be  lost  through  the  premature 
absorption  of  its  root,  the  full  space  occupied  by  it  should  be  main- 
tained by  some  suitable  retaining  device.  This  may  be  easily  and 
quickly  effected  by  making  small  pits  in  the  approximal  surfaces 
of  the  teeth  mesial  and  distal  to  the  space  and  inserting  the  ends 
of  a  section  of  the  wire  G  therein,  after  which  the  wire  may  be 
lengthened  by  a  few  pinches  of  the  regulating  pliers,  or  as  in 

Fig-  H5- 

Prolonged  Retention  of  Deciduous  Teeth. — For  reasons  not 
always  clearly  recognized,  one  or  more  of  the  deciduous  teeth 
are  occasionally  retained  beyond  the  normal  period.  This  is 
due  to  failure  of  absorption  of  the  root,  resulting  from  death  of  the 
pulp  or  other  cause.  In  this  event  the  succeeding  tooth  will  either 
be  prevented  from  erupting  or  will  be  deflected  to  a  malposition. 


26  MALOCCLUSION. 

Deflection  may  also  be  caused  by  the  survival  of  even  a  small 
portion  of  the  root. 

Loss  of  Permanent  Teeth. — What  we  have  already  said  in  re- 
gard to  the  mechanical  influence  of  the  deciduous  teeth  in  assist- 
ing the  normal  development  of  the  dental  arches  and  promotion 
of  harmony  of  the  facial  lines  is  equally  applicable  to  the  teeth  of 
the  permanent  set  up  to  the  period  of  their  full  eruption,  or  until 
the  last  of  the  molars  have  taken  their  positions.  This  is  a  point 
of  such  importance  that  it  should  be  carefully  considered  by  all 
teachers  and  students.  If  one  or  more  of  the  permanent  teeth 
anterior  to  erupting  molars  be  extracted,  the  wedging  process  so 
necessary  in  developing  the  arch  serves  only  to  close  the  space  thus 
made,  and  there  will  be  no  carrying  forward  of  the  teeth  and  pro- 
cess. The  evil  effects  already  enumerated  as  arising  from  unequal 
development  of  the  two  arches  will  follow.  It  should  also  be  borne 
in  mind  that  the  interdependence  of  the  teeth  is  so  great  at  all 
times  that  the  loss  of  one  or  more  at  any  period  in  their  history 
must  have  a  marked  influence  upon  the  remaining  teeth. 

Each  tooth  is  such  an  important  part  of  occlusion  that  its  loss 
should  be  seriously  considered  before  deciding  upon  its  removal. 
Occasionally  we  hear  of  some  one  advocating  the  sacrifice  of  the 
first  molar  (one  or  more)  as  a  prevention  or  cure  for  malocclusion. 
The  author  has  yet  to  see  a  single  case  where  the  loss  of  this  tooth 
has  not  been  followed  by  malocclusion,  or  aggravations  of  it  if 
formerly  existent,  often  of  a  far-reaching  and  serious  nature.  The 
loss  of  no  other  tooth  is  followed  by  so  many  and  so  marked  evil 
effects  as  that  of  the  first  molar,  especially  the  lower.  The  size, 
position  in  the  arch,  and  the  relations  of  this  tooth  to  the  others 
are  such  as  should  entitle  it  to  the  greatest  care  with  a  view  to 
its  longest  possible  preservation.  If  unavoidably  lost,  it  should 
be  immediately  replaced  by  some  form  of  artificial  substitute. 

The  author  has  seen  one  patient  where  all  of  the  first  perma- 
nent molars  were  extracted  at  the  age  of  nine  years,  with  a  view 
of  preventing  developing  malocclusion  of  the  incisors.  The  result 
was  shortening  of  both  of  the  arches  anterior  to  the  spaces,  greatly 
deforming  the  patient,  who,  although  a  young  lady  of  but  sixteen 
years,  yet  had  an  undeveloped,  sunken  appearance  about  the  mouth 
similar  to  that  of  an  edentulous  person,  while  apparently  no  relief 
had  been  given  to  the  crowded  arrangement  of  the  incisors. 


ETIOLOGY   OF    MALOCCLUSION.  2/ 

Fig.  14  shows  a  case  of  malocclusion,  the  cause  of  which  was 
directly  traceable  to  the  unwarranted  extraction  of  several  of  the 
permanent  teeth.  First,  the  two  lower  first  molars  were  extracted 
between  the  ninth  and  tenth  years  of  age.  The  main  support  and 
guide  as  to  the  normal  length  of  bite  being  thus  removed,  the  oc- 
clusal  edge  of  the  lower  incisors  impinged  upon  the  linguo-gingival 
inclines  of  the  upper,  rapidly  forcing  them  into  labial  protrusion, 
the  tendency  also  being  to  force  the  entire  lower  jaw  distally  and 
prevent  its  normal  development.  This  condition  was  further  inten- 
sified, first,  by  the  normal  lengthening  of  the  upper  arch  and 

FIG.  14. 


arrested  development  of  the  lower ;  and  second,  by  the  pressure  of 
the  lower  lip,  which  habitually  rested  between  the  upper  and  lower 
incisors. 

Later  followed  the  loss  of  other  teeth  by  extraction,  which  only 
augmented  the  untoward  conditions  already  enumerated,  the  re- 
sult being  the  establishment  of  such  marked  malocclusion  as  to 
make  the  dental  apparatus  almost  useless,  as  well  as  the  alteration 
of  the  features  of  the  patient  into  a  real  deformity;  and  this,  too, 
with  facial  lines  and  form  and  structure  of  teeth  naturally  much 
above  the  average.  Similar  cases  with  like  results  are  only  too 
common. 

The  evil  effects  arising  from  extraction  of  the  upper  lateral 
incisors  in  order  to  provide  space  in  the  crowded  arch  for  the  cus- 


28  MALOCCLUSION. 

pids  are  so  apparent  that  arguments  against  the  practice  seem  out 
of  place  in  a  modern  text-book.  The  abnormal  appearance  given 
to  the  face  in  the  region  of  the  nose  consequent  upon  the  dimin- 
ished size  of  the  upper  arch,  together  with  the  carnivorous  appear- 
ance of  the  mouth  by  the  resultant  prominence  of  the  cuspids,  is  a 
deformity  as  inexcusable  as  it  is  repulsive,  and  must  ever  reflect 
the  ignorance  and  incompetency  of  those  resorting  to  the  practice. 

For  a  further  discussion  of  this  point  we  would  refer  the  reader 
to  the  chapter  on  Treatment  of  Cases  belonging  to  Class  I  (see  also 
Figs.  208,  215,  and  216)  and  to  the  classical  articles  of  Drs.  Bogue 
and  Davenport  in  the  Dental  Cosmos,  December,  1899,  and  Inter- 
national Dental  Journal,  1892,  respectively. 

Tardy  Eruption  of  Permanent  Teeth. — It  occasionally  hap- 
pens that  a  tooth,  with  or  without  apparent  cause,  fails  to 
erupt  and  remains  imbedded  in  the  alveolus  for  months,  or  even 
years.  Usually  the  space  is  partially  or  wholly  closed  by  the  ad- 
joining teeth.  The  impaction  of  the  cuspid  is  the  most  common 
of  that  of  any  of  the  teeth,  owing  to  the  fact  that  it  erupts  after  both 
its  mesial  and  distal  associates  and  must  in  all  cases  meet  more 
or  less  resistance  from  them.  If,  later,  efforts  toward  eruption 
occur,  the  tooth  must  necessarily  be  deflected  or  force  other  teeth 
into  malposition. 

It  is  quite  probable  that  so-called  "third  dentitions"  are  only 
instances  of  tardy  eruption  of  some  one  or  more  of  the  permanent 
teeth. 

Supernumerary  Teeth. — Supernumerary  teeth,  as  their  name 
implies,  are  anomalies,  or  extra  teeth  above  the  normal  number  of 
thirty-two.  In  outline  they  rarely  resemble  any  of  the  typical  tooth 
forms,  being  most  commonly  peg-shaped  or  conical.  Although 
they  may  occur  in  any  part  of  the  dental  arches,  or  even  nearly 
cover  the  entire  vault  of  the  upper  arch,  as  shown  in  a  model  in 
the  author's  collection  and  also  in  two  or  three  other  well-known 
cases,  their  favorite  location  is  between  the  central  incisors,  in  the 
region  of  the  laterals,  or  in  the  bucco-embrasial  spaces  between  the 
molars.  The  reason  for  their  appearance  is  not  clearly  established. 
It  is  now,  however,  quite  commonly  attributed  to  atavism,  or  the 
occasional  effort  on  the  part  of  Nature  to  re-establish  original 
conditions.  The  typical  number  of  mammalian  teeth  is  supposed 
to  have  been  forty-four,  man  in  his  evolution  having  lost  four 


ETIOLOGY   OF    MALOCCLUSION.  29 

incisors  and  eight  premolars.  It  is  believed  that  these  supernu- 
meraries are  some  of  these  suppressed  teeth  reappearing  in  a 
rudimentary  form. 

These  teeth  frequently  take  their  positions,  especially  in  the 
incisive  region,  just  before  the  eruption  of  the  permanent  teeth, 
with  the  effect  of  deflecting  erupting  permanent  teeth  from  their 
normal  course. 

Fig.  15  represents  a  model  in  the  author's  collection  in  which 
two  supernumeraries  are  clearly  shown,  one  between  the  centrals 

FIG.  15. 


and  the  other  distal  to  the  cuspid  and  somewhat  resembling  it 
Another  irregularity  is  also  here  shown  in  that  the  right  central  is 
greatly  oversized. 

Habits. — The  habits  of  sucking  the  thumb,  lip,  or  tongue,  so 
frequently  formed  by  young  children,  while  rarely  causing  dis- 
placement of  the  deciduous  teeth,  will  if  persisted  in  during  the 
eruption  of  the  permanent  incisors,  cause  marked  malocclusion. 

In  the  case  of  thumb-sucking  fortunately  the  habit  is  usually 
broken  before  any  marked  evil  effects  result,  so  that  cases  where 
malocclusion  has  really  resulted  from  this  habit  are  rare  and  easily 
recognized.  The  upper  incisors  and  cuspids  are  always  drawn 
forward  and  to  one  side,  according  as  the  thumb  of  the  right  or 
left  hand  has  been  used,  while  pressure  from  the  back  of  the  thumb 


30  MALOCCLUSION. 

upon  the  lower  incisors  causes  their  marked  displacement  lin- 
gually.  These  cases  are  frequently  confounded  with  those  of  pro- 
trusion belonging  to  Division  i  of  Class  II.  The  conditions  and 
results  are  very  different,  the  latter  being  mouth-breathers, — the 
former  never,  as  such  action  would  be  a  physical  impossibility. 
This  is  illustrated  in  the  difficulty  which  infants  experience  in  nurs- 
ing while  suffering  from  temporary  obstruction  of  the  nasal  pas- 
sages resulting  from  colds. 

The  pernicious  habit  of  biting  the  lower  lip,  or  pressing  the  oc- 
clusal  edges  of  the  upper  incisors  against  its  outer  surface,  has  a 

FIG.  16. 


tendency  to  move  the  upper  central  incisors  forward,  thus  lessen- 
ing their  natural  resistance  to  the  narrowing  of  the  lateral  halves 
of  the  arch.  Such  a  case  is  shown  in  Fig.  16.  In  this  case  the 
malocclusion  was  easily  reduced,  but  the  habit  of  biting  the  lip  was 
still  persisted  in  for  a  period  of  nearly  two  years,  necessitating  the 
continued  wearing  of  the  retaining  device  for  that  length  of  time. 
This  habit  is  more  common  than  seems  to  be  generally  supposed, 
is  often  extremely  difficult  to  overcome,  and  probably  accounts 
for  many  ultimate  failures  in  tooth  regulating.  It  is  always  a 
marked  accompaniment  of  cases  belonging  to  Division  i  of  Class 
II  and  its  subdivision,  and  unless  it  be  overcome  and  the  normal 
functions  of  the  lips  regained  the  incisors  cannot  be  kept  in  their 


'   ETIOLOGY   OF    MALOCCLUSION.  3! 

normal  positions.  The  device  described  and  illustrated  in  Fig. 
164  is  apparently  the  most  useful  in  combating  this  habit.  This 
same  device  may  also  be  used  to  successfully  overcome  the  habit 
of  thumb-sucking. 

The  other  habit,  though  quite  rare,  that  of  resting  the  tongue 
between  the  upper  and  lower  incisors,  produces  the  effect  shown 
in  Fig.  17.  The  pressure  upon  the  incisal  edges  prevents  full 
eruption  and  holds  the  teeth  in  infra-occlusion,  while  the  molars, 

FIG.  17. 


being  held  apart  much  of  the  time,  lengthen  into  positions  of 
supra-occlusion  from  lack  of  resistance. 

Disuse. — According  to  a  well-known  physiological  law,  the  use 
of  a  part  tends  to  stimulate  its  growth  and  development,  as  illus- 
trated in  the  well-known  example  of  the  blacksmith's  arm,  while 
disuse  tends  toward  lack  of  development,  or  even  atrophy,  as  illus- 
trated in  the  wings  of  domestic  fowls  as  contrasted  with  those  of 
wild  fowls. 

The  structure  and  history  of  the  jaws  and  teeth  show  that  they 
were  intended  for  much  use.  There  can  be  little  doubt  that 
modern  methods  of  food  preparation  have  a  marked  general  effect 
in  causing  malocclusion  from  the  lack  of  the  development  of  the 
jaws  through  diminished  use. 


32  MALOCCLUSIOIST. 

Nasal  Obstructions. — When  there  is  normal  nasal  respiration  and 
normal  relations  of  the  dental  arches,  the  teeth,  and  the  muscles, 
the  conditions  are  such  as  to  perfectly  maintain  the  equilibrium  and 
the  mutual  support  necessary  to  the  normal  development  of  the 
teeth  and  jaws.  Should  nasal  obstruction  occur  in  the  developing 
child,  inducing  habitual  mouth-breathing,  immediately  the  equi- 
librium is  disturbed,  the  lips  and  muscles  are  placed  on  a  different 

FIG.  18. 


tension,  and  pressure  upon  the  arches,  instead  of  being  equal,  is 
localized,  being  greater  than  normal  at  some  points  and  less 
at  others.  No  matter  how  strenuously  it  may  be  denied,  malocclu- 
sion  of  the  teeth  and  abnormalities  in  the  formation  of  the  bones 
of  the  jaws  naturally  follow.  The  undeveloped  nose  and  adjacent 
region  of  the  face,  the  vacant  look,  the  short  upper  lip,  the  open 
mouth,  and  irregular  teeth  of  the  mouth-breather  are  common 
sights  familiar  to  all.  See  Fig.  18,  also  Fig.  24. 

One  has  but  to  observe  those  who  pass  on  the  street  to  be 


ETIOLOGY    OF    MALOCCLUSION.  33 

convinced  of  the  great  prevalence  and  deforming  effects  of  mouth- 
breathing,  or  to  examine  the  patients  in  a  large  clinic  to  be  con- 
vinced of  the  frequent  close  association  of  the  practice  and  mal- 
occlusion. 

Abnormal  Frenum  Labium. — A  somewhat  common  form  of 
malocclusion  is  distinguished  by  a  space  between  the  upper  central 
incisors,  Fig.  19,  and  occasionally,  though  very  rarely,  between 
the  lower  centrals.  This  space  varies  in  width,  the  distance  being 
from  one  to  four,  and  even  five  millimeters,  always  presenting  an 
unpleasing  appearance  and  interfering  with  speech  in  proportion 
to  its  width. 

FIG.  19. 


The  cause  of  the  deformity  is  abnormal  development  and  attach- 
ment of  the  frenum  labium,  which,  instead  of  being  normal  in 
size  and  ending  in  its  attachment  to  the  gum  about  five  millimeters 
above  the  gingiva,  not  only  reaches  the  gingiva,  but  passes  di- 
rectly through  between  the  teeth  and  is  attached  to  the  likewise 
overdeveloped  mesio-lingual  tuft.  This  strong  fibrous  ligament 
keeps  the  teeth  separated,  not  only  by  its  passive  presence,  but  as 
well  by  its  action  mechanically,  as  may  be  easily  proven  by  gently 
grasping  the  lip  between  the  thumb  and  finger  and  moving  it  from 
side  to  side  in  imitation  of  its  normal  movements. 

Whether  this  abnormal  condition  of  the  frenum  results  from  an 
abnormal  suture  of  the  bones  is  not  clear,  yet  it  is  probable  that 
it  is  nearly  always  an  accompaniment,  although  the  author  has 
seen  some  cases  where  the  union  of  the  bones  seemed  to  be 
normal.  A  more  exact  knowledge,  to  be  gained  through  the  use 
of  the  X  rays  in  a  satisfactory  number  of  these  cases,  is  much 
needed. 


34  MALOCCLUSION. 

In  some  cases  there  is  not  only  a  space  between  the  upper  in- 
cisors, but  the  entire  alveolus  seems  to  be  drawn  upward  and  out- 
ward, causing  more  or  less  of  a  space  between  the  upper  and  lower 
incisors  similar  to  the  result  produced  by  sucking  the  tongue. 


CHAPTER    IV. 

CLASSIFICATION  AND  DIAGNOSIS  OF  MALOCCLUSION. 

IN  every  case  of  malocclusion  presented  for  treatment,  the  im- 
portance of  a  thorough  study  and  a  correct  diagnosis  cannot  be 
overestimated.  Otherwise  any  plan  of  treatment  will  be  very  un- 
certain as  to  results;  in  fact,  is  most  apt  to  lead  to  failure,  with  all 
of  its  embarrassments. 

From  an  extensive  intercourse  with  dentists  and  students  the 
author  is  impressed  with  the  belief  that  although  diagnosis  is  the 
question  of  greatest  importance,  it  is  yet  apparently  the  least  intel- 
ligently studied  and  comprehended. 

In  the  beginning  we  wish  to  thoroughly  impress  the  necessity 
for  complete  separation  of  diagnosis  from  treatment.  This  state- 
ment seems  necessary  for  the  reason  that  we  have  so  frequently 
noted  a  mental  conflict  in  the  endeavor  to  consider  the  two  to- 
gether, the  consideration  of  such  questions  as  regulating  appliances 
and  extraction  apparently  preceding  or  being  confused  with  diag- 
nosis before  the  facts  upon  which  treatment  should  be  based  have 
had  due  consideration.  As  a  matter  of  fact,  if  the  diagnosis  of  any 
given  case  be  first  thoroughly  mastered,  the  line  of  treatment  and 
the  appliances  necessary  to  bring  about  the  various  tooth  move- 
ments required  are,  in  nearly  every  instance,  clearly  indicated,  even 
to  the  devices  necessary  for  retaining  the  teeth  when  correctly 
placed.  In  order  to  diagnose  any  case  of  malocclusion  correctly 
it  is  necessary  to  be  familiar  with,  first,  the  normal  or  ideal  occlu- 
sion of  the  teeth;  second,  the  normal  facial  lines.  These  must  be 
so  fixed  in  the  mind  as  to  form  the  basis  from  which  to  reason,  all 
deviations  from  the  normal  being  intelligently  noted;  and  it  must 
follow  that  in  the  absence  of  clear,  fixed,  and  definite  ideas  as  to 


CLASSIFICATION    AND   DIAGNOSIS    OF    MALOCCLUS1ON.  35 

the  normal,  the  limits  or  boundary  lines  of  the  abnormal  must  also 
be  vague  and  indefinite,  and  the  line  of  treatment  be  the  merest 
empiricism. 

As  already  stated,  there  are  but  seven  distinct  positions  which 
teeth  in  malocclusion  can  occupy.  These,  with  their  inclinations, 
form  combinations  practical!}-  limitless  in  variety,  to  the  casual 
observer  presenting  differences  very  pronounced.  Failure  to 
grasp  the  underlying  principles  of  occlusion  has  given  rise  to  the 
belief  that  each  case  differs  radicallv  from  all  others,  necessitating- 

-  "  o 

the  invention  and  construction  of  an  appliance  to  meet  its  special 
requirements. 

In  reality  all  cases  of  malocclusion  may  be  as  readily  arranged 
in  well-defined  classes  as  plants,  animals,  or  the  elements,  and 
having  a  thorough  knowledge  of  the  distinguishing  characteristics 
of  occlusion  and  of  the  facial  lines  peculiar  to  each  class,  the  diag- 
nosis of  any  given  case  is  greatly  simplified.  At  the  same  time, 
familiarity  with  the  possibilities  of  tooth  movement  and  the  changes 
necessary  in  each  distinct  and  separate  class  to  attain  harmony  in 
occlusion  and  in  the  facial  lines,  and  acquaintance  with  the  standard 
appliances  best  suited  to  produce  these  changes  in  each  special 
class,  will  reduce  the  time  and  difficulties  of  treatment  to  the  mini- 
mum. 

In  diagnosing  cases  of  malocclusion  we  must  consider, — first, 
the  mesio-distal  relations  of  the  jaws  and  dental  arches;  second, 
the  individual  positions  of  the  teeth.  For  convenience  of  diagnosis 
two  points  have  been  selected  from  which  to  note  variations  from 
the  normal  in  the  arches.  These  points  are  represented  by  dark 
lines  in  the  engravings,  and  indicate  the  normal  mesio-distal  rela- 
tions of  the  cuspids  and  of  the  mesio-buccal  cusps  of  the  upper 
first  molars,  Fig.  2,  or  their  relative  relations,  as  in  Figs.  22,  25, 
and  30. 

Of  course,  in  determining  the  mesio-distal  variations,  all  of  the 
teeth  are  to  be  taken  into  consideration,  but  the  points  indicated 
have  long  been  favorites  with  the  author  in  beginning  the  diag- 
nosis of  cases,  for  the  reason  that  the  first  molars  and  cuspids  are 
far  more  reliable  as  points  from  which  to  judge.  This  is  due  to  the 
fact  that  they  are  found  to  occupy  normal  positions  more  often  than 
any  of  the  other  teeth,  the  molars  being  less  restrained  in  taking 
their  positions,  and  the  cuspids,  owing  to  their  history  and  great 


36  MALOCCLUSION. 

size,  force  their  way,  usually,  into  relatively  normal  positions  in  the 
arches.  In  diagnosing  all  cases  it  is  important  that  the  occlusion 
of  both  the  lateral  halves  of  both  arches  receive  equal  and  careful 
attention. 

FIG.  20. 


FIG.  21. 


A 


CLASSIFICATION    AND   DIAGNOSIS   OF    MALOCCLUSION. 


37 


Class  I,  represented  by  Fig.  20. — Relative  positions  of  jaws  and 
dental  arches  mesio-distally  normal,  with  first  molars  usually  in 
normal  occlusion,  although  one  or  more  may  be  in  lingual  or  buc- 
cal  occlusion.  (Exceptions  resulting  from  extraction  noted  later.) 
Cases  belonging  to  this  class  far  exceed  in  number  those  of  all 
other  classes  combined  (see  table),  ranging  from  the  simple  over- 
lapping of  a  single  incisor  to  the  most  complex  derangement  involv- 
ing the  positions  of  all  the  teeth  of  both  arches,  Fig.  21.  The 
average  case  is  where  the  arches  are  more  or  less  reduced  in  size, 
with  a  corresponding  bunching  of  the  teeth,  usually  confined  to 
the  incisors  of  both  upper  and  lower  arches.  Fig.  20  represents  an 
average  case.  The  molars  of  each  side  are  in  normal  mesio-distal 
relations,  the  arches  shortened  and  the  anterior  teeth  crowded. 

Class  II. — Relative  mesio-distal  relations  of  jaws  and  dental 
arches  abnormal,  all  the  lower  teeth  occluding  distally  to  normal 


FIG.  23. 


the  width  of  one  bicuspid  tooth  and  producing  very  marked  inhar- 
mony  in  the  incisive  region  and  in  the  facial  lines. 

This  great  class  has  two  divisions,  each  having  a  subdivision. 
THE  FIRST  DIVISION  is  characterized  by  more  or  less  narrowing  of 
the  upper  arch  and  lengthened  and  protruding  upper  incisors,  Figs. 
22  and  23,  accompanied  by  abnormal  functions  of  the  lips  and  some 
form  of  nasal  obstruction  and  mouth-breathing,  Fig.  24. 


MALOCCLUS10N. 

FIG.  24. 


FIG.  25. 

•MM 

468       468 

•"«%  *i|***^n 

,-v-v-y 


468    468 


CLASSIFICATION    AND    DIAGNOSIS    OF    MALOCCLUSION. 

FIG.  26. 


39 


4O  MALOCCLUSION. 

In  the  subdivision  of  the  First  Division  one  of  the  lateral  halves 
only  is  in  distal  occlusion,  the  relation  of  the  other  lateral  half  of 
the  lower  arch  being  normal,  all  as  shown  in  Fig.  25. 

THE  SECOND  DIVISION  is  characterized  by  less  narrowing  of  the 
upper  arch,  lingual  inclination  of  the  upper  incisors,  and  more  or 
less  bunching  of  the  same,  as  in  Fig.  26,  and  is  associated  with 
normal  nasal  and  lip  function,  Fig.  27. 

FIG.  28. 


The  peculiarities  of  the  subdivision  of  the  Second  Division  differ 
from  those  of  the  main  division,  just  described,  in  that  one  of  the 
lateral  halves  of  the  lower  arch  only  is  in  distal  occlusion,  the  other 
being  normal,  as  in  Fig.  28. 

Class  III. — The  relation  of  the  jaws  and  dental  arches  is  ab- 
normal, the  lower  being  more  or  less  mesial  to  the  upper.  There 
is  one  division  and  a  subdivision. 


CLASSIFICATION    AND   DIAGNOSIS   OF    MALOCCLUSION.  4! 

THE  DIVISION  comprises  cases  in  which  all  the  lower  teeth  oc- 
clude mesial  to  normal  the  width  of  one  bicuspid  tooth,  as  shown 
in  Fig.  29,  or  even  more  in  extreme  cases,  Fig.  30.  The  arrange- 


FIG.  29. 


FIG.  30. 


ment  of  the  teeth  in  the  arches  varies  greatly  in  this  class,  from  that 
of  quite  even  alignment  to  considerable  bunching  and  overlapping, 
especially  in  the  upper  arch,  Fig.  275.  There  is  usually  a  lingual 


42  MALOCCLUS1ON. 

inclination  of  the  lower  incisors  and  cuspids;  which  becomes  more 
pronounced  in  proportion  to  the  age  of  the  patient,  due  to  the  pres- 
sure of  the  lower  lip  in  the  effort  to  close  the  mouth. 

The  inharmony  in  size  of  arches  is  usually  due  to  the  asym- 
metrical development  of  the  maxillary  bones,  the  angle  of  the 
lower  jaw  being  more  obtuse  than  normal,  but  it  may  be  the  re- 
sult of  overdevelopment  in  the  body  of  the  jaw.  This  seems  to  be 
in  some  cases  limited  to  certain  localities,  as  in  Fig.  175.  Another 
model  in  the  author's  collection  shows  local  overdevelopment  of 
both  the  lateral  halves  between  the  bicuspids,  one  space  being 
greater  than  the  width  of  one  bicuspid  tooth,  the  other  not  quite 
so  great. 

In  other  cases  the  jaw  seems  to  be  normal  in  form,  the  protrusion 
apparently  being  caused  by  the  temporo-maxillary  articulation 
being  farther  anterior  than  normal,  this  probably  being  due  to 
the  gradual  sliding  forward  of  the  condyles  and  to  modification  of 
the  fossa. 

In  all  cases  of  malocclusion  belonging  to  this  class  the  marring 
of  the  facial  lines  is  most  noticeable,  amounting  in  some  instances 
to  pronounced  deformities,  Fig.  9,  also  Fig.  279. 

In  the  subdivision  the  general  characteristics  are  the  same  as 
those  of  the  Division,  except  that  the  inharmony  is  less  in  degree, 
in  that  one  of  the  lateral  halves  of  the  arch  only  is  in  mesial  occlu- 
sion, the  other  being  normal,  as  in  Fig.  31,  the  arches  crossing  in 
the  region  of  some  of  the  incisors. 

It  is  quite  probable  that  all  cases  met  with  will  be  found  to  be 
embraced  in  the  above  classification.  There  still  remains,  how- 
ever, one  possible  class, — viz,  where  one  of  the  lateral  halves  of  the 
lower  arch  is  in  mesial  occlusion  while  the  other  is  in  distal,  but 
cases  having  these  characteristics  are  so  rare  that  no  further  refer- 
ence to  them  is  necessary. 

In  diagnosing  cases  according  to  the  above  classification  it 
will  be  seen  that  each  of  the  lateral  halves  of  the  arches  must  be  con- 
sidered as  distinctive,  yet  of  equal  importance. 

In  developing  cases  the  full  mesial  or  distal  relations  of  the 
opposing  lateral  halves  of  the  arches  may  not  be  complete,  but  the 
teeth  may  be  in  transition,  apparently  occluding  upon  the  points 
of  the  cusps,  suggesting  at  first  sight  either  of  two  classes,  but 
upon  careful  inspection  it  will  be  found  that  a  majority  of  the 


CLASSIFICATION    AND   DIAGNOSIS   OF    MALOCCLUSION. 


43 


inclined  planes  favor  either  one  or  the  other  of  these  classes,  the 
co-relation  of  the  first  molars  being  of  course  the  most  important 
factor.  ,  ! 

FIG.  31. 


The  loss  of  a  tooth  by  extraction  or  otherwise  is  usually  fol- 
lowed by  such  marked  changes  in  the  positions  of  the  remaining 
teeth  that  diagnosis  is  sometimes  greatly  complicated.  There- 
fore great  care  and  judgment  should  be  exercised,  making  allow- 
ance for  the  tipping  of  teeth  and  other  changes  which  have  taken 


44  MALOCCLUSION. 

place  as  a  result  of  extraction,  in  order  to  determine  their  original 
positions. 

The  classification  of  malocclusion  is  here  given  in  brief,  for  con- 
venience of  study  and  for  ready  reference. 

Class  I. — Arches  in  normal  mesio-distal  relations. 
Class  II. — Lower  arch  distal  to  normal  in  its  relation  to  upper 
arch. 

DIVISION  i. — Bilaterally  distal,  protruding  upper  incisors. 

Usually  mouth-breathers. 
Subdivision. — Unilaterally  distal,  protruding  upper  incisors. 

Usually  mouth-breathers. 
DIVISION   2. — Bilaterally   distal,   retruding  upper  incisors. 

Normal  breathers. 
Subdivision. — Unilaterally  distal,  retruding  upper  incisors. 

Normal  breathers. 

Class  III. — Lower  arch  mesial  to  normal  in  its  relation  to  upper 
arch. 

DIVISION. — Bilaterally  mesial. 
Subdivision. — Unilaterally  mesial. 

Out  of  several  thousand  cases  of  malocclusion  examined,  the  pro- 
portion per  thousand  belonging  to  each  class  was  as  follows: 

Class  1 692 

Class  II. 

Division  1 90 

Subdivision   34 

Division  2 42 

Subdivision 100 

Class  III,  Division 34 

Subdivision 8 

i  coo 


ALVEOLUS    AND    PERIDENTAL    MEMBRANE.  45 

CHAPTER    V. 

ALVEOLUS  AND  PERIDENTAL  MEMBRANE. 

BEFORE  entering  upon  the  consideration  of  the  treatment  of 
malocclusion  it  will  be  necessary  to  consider  the  alveolus  and  peri- 
dental  membrane,  as  their  importance  is  perhaps  greater  in  ortho- 
dontia  than  in  any  other  branch  of  dentistry, — in  fact,  is  only 

FIG.  32. 


secondary  to  that  of  the  teeth  themselves, — and  it  is  owing  to  our 
intelligent  comprehension  and  management  of  these  tissues  that 
we  are  enabled  to  correct  inharmonious  positions  of  the  teeth. 

Alveolar  Process. — The  alveolar  process,  Fig.  32,  is  that  portion 
of  the  maxillary  bones  formed  for  the  reception  and  support  of  the 
roots  of  the  teeth,  which  are  lodged  in  alveoli  or  sockets  accurately 


46  MALOCCLUSION. 

fitting  their  surfaces.  The  alveolar  process  seems  to  be  wholly 
subservient  to  the  uses  of  the  teeth,  as  it  does  not  appear  befort 
their  eruption  and  slowly  disappears  by  absorption  after  their  re- 
moval. It  conforms  to  whatever  position  the  teeth  arrange  them- 
selves in,  regardless  of  regularity,  and  in  correcting  their  mal- 
positions the  process  readily  forms  itself  about  their  roots  in  their 
new  positions,  so  that  a  crowded  and  greatly  diminished  arch  may 
be  much  enlarged  and  the  alveolus  will  become  completely  re- 
formed and  modified,  as  will  be  shown  in  numerous  cases  hereafter. 
In  health  the  alveolar  process  surrounds  the  roots  of  the  teeth 

FIG.  33- 


to  nearly  the  height  of  the  gingival  line.  The  thickness  of  the 
process  on  both  the  labial  and  lingual  surfaces  varies  gr.eatly  over 
different  portions  of  the  roots  and  in  different  individuals,  but 
perhaps  in  each  case  the  distribution  is  best  suited  to  resist  the 
force  of  mastication. 

It  is  usually  very  thinly  distributed  over  the  labial  surfaces  of 
the  roots  of  the  upper  incisors  and  cuspids  and  upper  thirds  of  the 
bicuspids  and  molars,  always  presenting  more  or  less  of  a  fluted 
appearance  which  is  readily  detected  by  pressure  of  the  finger,  and 
is  very  noticeable  in  carefully  made  models,  enabling  us  to  trace 
quite  accurately  the  exact  positions  of  the  roots  of  these  teeth, 
Fig.  33.  At  the  immediate  margin  of  the  process  it  is  thin,  but 


ALVEOLUS    AND    PERIDENTAL    MEMBRANE.  47 

abruptly  thickens,  and  on  the  buccal  surfaces  of  the  molars  and 
bicuspids  amounts  to  a  well-defined  ridge,  in  some  instances  fully 
one-eighth  of  an  inch  in  thickness. 

The  alveolus  on  the  lingual  surface  of  the  upper  teeth  is  also 
very  thin  at  the  margin,  gradually  and  evenly  thickening  toward 
the  ends  of  the  roots,  an  exception  being  on  the  lingual  surfaces  of 
the  roots  of  the  second  and  third  molars,  it  there  assuming  a  quite 
uniform  thickness  in  order  to  form  the  groove  and  fossa  for  the 
posterior  palatine  artery. 

The  alveolus  covering  the  buccal  roots  of  the  lower  teeth  is 
thin  at  the  margin,  gradually  and  evenly  becoming  thicker  toward 
the  center  of  the  body  of  the  jaw,  while  the  labial  plate  covering 
the  roots  of  the  incisors  and  cuspids  is  thickest  near  the  margin, 
the  remaining  covering  being  very  thin  and  sometimes  even 
missing  in  portions,  especially  if  the  root  be  markedly  prominent. 

The  distribution  of  the  alveolus  over  the  lingual  surface  of  the 
roots  of  the  lower  teeth  is  thin  at  the  margin,  gradually  thickening 
toward  the  mylo-hyoidian  ridge. 

The  sockets  are  quite  loosely  formed  about  the  teeth  during  their 
eruption  and  for  some  time  after,  so  that  considerable  movement 
of  the  teeth  is  possible  without  bone  displacement.  The  sockets, 
however,  gradually  become  diminished  in  size  and  fit  the  roots 
and  neck  of  the  teeth  more  closely  with  advancing  age,  greatly 
limiting  tooth  movement  without  displacement  of  the  process. 

The  broad,  funnel-shaped  opening  of  the  anterior  palatine  for- 
amen is  situated  in  the  median  line  just  posterior  to  the  central 
incisors.  The  septum  of  bone  between  this  and  the  root  of  the  tooth 
is  often  slight,  therefore  care  should  be  exercised  not  to  injure 
the  artery  when  it  may  be  found  desirable  to  surgically  remove  a 
portion  of  the  process  in  this  region  in  order  to  expedite  the 
lingual  movement  of  malposed  centrals. 

The  alveolar  process  has  an  external  and  an  internal  plate.  The 
outer  plate  forms  the  external  surface  of  the  bone;  the  inner 
plates  form  the  sockets  or  alveoli  of  the  teeth.  The  structure  of 
both  the  external  and  internal  plates  is  quite  compact,  but  is  freely 
perforated  by  minute  openings  for  the  transmission  of  nutrient 
vessels.  Between  the  external  and  internal  plates  the  bone  is  far 
less  compact,  being  very  cancellous  and  similar  to  the  internal 
structure  of  the  larger  bones.  This  cancellated  structure,  Fig.  34, 


MALOCCLUSION. 


permits  of  considerable  bending  of  the  process  without  breaking, 
especially  in  the  case  of  young  patients.  As  age  advances  the  bone 
becomes  more  dense  and  unyielding. 

FIG.  34. 


Strongly  adherent  to,  and  closely  covering,  the  external  plate  of 
the  alveolar  process  is  the  periosteum,  which  in  a  modified  form 
dips  down  into  the  alveoli  to  form  the  peridental  membrane. 

Peridental  Membrane. — The  peridental  membrane  is  a  strong, 
fibrous  membrane  forming  a  close,  cushion-like  investment  of  the 
roots  of  the  teeth,  and  is  the  medium  of  attachment  between  the 
alveolus  and  cementum.  It  is  composed  largely  of  inelastic  fibers 
of  connective  tissue,  and  is  richly  supplied  with  nutrient  vessels, 
nerves,  cells,  and  glands.  Its  function  is  three- fold : 


ALVEOLUS    AND    PERIDENTAL    MEMBRANE.  49 

First,  vital,  for  the  formation  of  the  alveolus  on  one  side  and 
the  cementum  on  the  other. 

Second,  sensory,  being  the  seat  of  the  sense  of  touch  of  the  tooth, 
through  which  the  most  delicate  contact  with  the  tooth  is  recog- 
nized. 

Third,  physical,  holding  the  tooth  in  position  in  the  alveolar 
socket  and  resisting  the  movements  of  teeth  in  the  various  direc- 
tions incident  to  occlusion  and  mastication. 

Cells. — Of  the  cells  found  in  the  peridental  membrane  there  are 
five  kinds: 

First,  the  fibroblasts,  for  formation  of  fibers  of  the  membrane. 
These  are  spindle-shaped  cells  found  lying  between  the  fibers. 

Second,  osteoblasts.  These  are  cuboidal  cells  for  formation  of 
the  alveolus,  and  are  found  close  to  the  layer  of  bone  or  imbedded 
therein. 

Third,  cementoblasts,  or  formative  cells  of  the  cementum.  These 
flattened  and  irregular  cells  are  found  in  close  contact  with  the 
surface  of,  or  partially  inclosed  in,  the  cementum. 

Fourth,  osteoclasts,  or  cells  whose  function  it  is  to  disintegrate 
calcified  tissue,  found  to  vary  greatly  in  numbers  and  location. 

Fifth,  glands,  the  function  of  which  is  yet  imperfectly  under- 
stood. 

Arrangement  of  Fibers. — The  arrangement  of  fibers  of  the  peri- 
dental  membrane  is  very  complex.  More  than  a  general  descrip- 
tion is  here  impossible.  The  course  which  the  fibers  take  varies 
greatly  in  different  portions  of  the  root.  Figs.  35  and  36  show 
a  longitudinal  section  of  the  tooth,  membrane,  alveolus,  and  gum, 
which  will  give  a  general  idea  of  the  arrangement  of  these  fibers. 

It  will  be  seen  that  the  fibers  about  the  neck  of  the  tooth  pass 
outward  more  or  less  at  right  angles,  some  blending  with  the  gum, 
other  branches  curving  up  to  support  the  gingiva,  while  others 
blend  with  those  at  the  beginning  of  the  alveolus.  Still  others 
anastomose  with  those  from  the  gingival  portion  of  the  adjoining 
teeth,  forming  a  tough  ligament  known  as  the  dental  ligament. 

The  manner  of  attachment  of  the  fibers  to  the  alveolus  at  its 
beginning  is  noteworthy.  Not  only  are  they  attached  to  it  at 
points  nearest  the  cementum,  but  some  are  attached  at  the  top  of 
the  bone  while  others  pass  over  to  form  attachment  with  the 
alveolus  on  its  outer  surface  (well  shown  in  the  microscopical  sec- 

5 


5O  MALOCCLUSION. 

tion  illustrated  in   Fig.  36),  thus   making  the  strongest  possible 
attachment  to  prevent  lateral  strain. 

At  the  beginning  of  the  alveolus,  and  a  little  below,  the  fibers 
are  at  right  angles  to  the  long  axis  of  the  tooth.     They  soon, 

FIG.  35. 


A  drawing  of  a  longitudinal  section  of  an  incisor  of  a  kitten  with  crypt  of 
permanent  tooth.  The  labial  is  to  the  right  and  the  lingual  to  the  left.  The 
bone  is  represented  in  the  light  stippling.  The  thinness  of  the  labial  plate  of 
the  process  is  shown,  with  the  periosteum  and  the  muscle  attached.  The 
lingual  plate  of  the  bone  is  much  thicker. 


ALVEOLUS    AND    PERIDENTAL    MEMBRANE. 


FIG.  36. 


Longitudinal  section  of  the  peridental  membrane,  showing  the  gingival 
and  upper  third  of  the  alveolar  portion. 

B.  dentin,  showing  the  light  band  at  the  outer  border.  C,  cementum,  show- 
ing at  the  occlusal  extremity  a  thickening  where  the  fibers  which  pass  up  to 
support  the  gingivae  are  attached.  D,  bone  of  the  alveolar  process.  The 
short,  strong  fibers  which  support  the  tooth  against  lateral  strain  are  seen 
stretching  from  the  cementum  to  the  bone.  A  blood-vessel  cut  longitudinally 
is  seen  crossing  these  fibers. 


52  MALOCCLUSION. 

however,  begin  to  incline,  and  a  little  farther  down  their  course  is 
oblique  until  we  have  neared  the  apex  of  the  root.  These  serve 
to  suspend  the  tooth  in  its  socket.  As  we  near  the  apex  of  the 
root  the  fibers  again  assume  a  direction  more  or  less  horizontal, 
while  at  the  apex  their  course  is  at  right  angles  with  the  surface. 

Fig.  37  shows  a  transverse  section  in  the  alveolar  portion,  in 
which  the  general  arrangement  of  the  fibers  from  this  aspect  is  well 
shown,  and  it  will  be  seen  that  some  of  the  bundles  of  fibers  pass 
out  from  the  cementum  at  right  angles  to  its  surface  and  pursue 
the  shortest  course  to  the  alveolus,  while  other  bundles  are  sent 
out  at  different  angles  and  cross  on  their  way  to  the  alveolus. 
Others  still  curve  laterally,  this  course  being  more  pronounced  at 
the  angles  of  the  root,  especially  the  labial  angles,  to  prevent  the 
turning  of  the  tooth  in  its  socket.  The  course  of  these  latter  is 
especially  well  shown  in  the  reproduction  of  the  microscopical 
section  in  Fig.  38. 

The  fibers  soon  after  springing  from  the  cementum  break  up 
in  smaller  fibers  which  pursue  more  or  less  of  a  parallel  course,  or 
in  some  instances  pass  around  the  numerous  nerves  and  blood- 
vessels in  their  course  outward.  These  again  unite  into  larger 
and  coarser  fibers  as  they  aproach  the  alveolus.  In  young  sub- 
jects a  large  portion  of  the  alveolus  is  often  missing  between  the 
teeth,  as  in  Fig.  38,  in  which  case  the  fibers  pass  directly  across  to 
unite  with  those  of  the  adjoining  teeth. 

The  attachment  of  the  fibers  to  the  cementum  and  bone  is  most 
secure,  the  ends  being  literally  built  into  the  bony  substance, 
actually  penetrating  the  cementum  to  its  union  with  the  dentin. 
while  the  alveolar  portions,  in  addition  to  the  strong  attachments 
gained  by  the  numerous  bay-like  excavations  in  its  surface,  also 
penetrate  the  very  substance;  in  reality  the  bone  has  been  deposited 
about  the  fibers. 

Although  the  fibers  are  composed  of  inelastic  tissue  and  their 
attachment  is  most  secure,  yet  it  is  known  that  the  teeth  admit  of 
slight  movement  normally.  This  wise  provision  doubtless  often 
prevents  shock  or  fracture,  and  probably  renders  more  efficient  their 
occlusal  planes  in  masticating  food.  This  slight  movement  is 
probably  due  to  the  bundles  of  fibers  pursuing  different  directions 
in  their  course,  so  that  none  are  on  actual  tension. 

No  thoughtful  person  can  study  the  arrangement  of  the  fibers 


ALVEOLUS  AND  PERIDENTAL  MEMBRANE. 
FIG.  37. 


53 


Drawing  of  a  transverse  section  of  the  peridental  membrane  in  the  upper 
third  of  the  alveolar  portion,  showing  the  thickness  of  the  labial  plate,  with 
periosteum  and  muscle  attached,  and  the  fibers  resisting  rotation. 

The  tooth  shows  two  layers  of  cementum.  The  bone  is  represented  by  the 
lighter  stippled  part,  which  shows  its  spongy  character.  On  the  mesial  side 
(to  the  left)  the  septum  is  not  complete  and  the  fibers  pass  to  the  distal  of 
the  incisor,  which  is  not  shown.  The  labial  plate  of  bone  (above)  is  very 
thin,  and  shows  the  periosteum  with  its  two  layers  and  the  muscle  attached 
to  it. 


54 


MALOCCLUSION. 


of  the  peridental  membrane  without  being  impressed  with  their 
wonderful  perfection  for  resisting  the  various  tooth  movements 
incident  to  occlusion  and  mastication,  and  a  knowledge  of  this 
arrangement  is  of  peculiar  interest  to  the  orthodontist,  enabling 

FIG.  38. 


Transverse  section  of  a  lateral  incisor  and  its  membrane  from  the  occlusal 
third  of  the  alveolar  portion.  A,  the  pulp,  showing  blood-vessels  and  nerves. 
B,  dentin.  C,  cementum,  showing  two  layers.  The  outer  of  the  two  layers 
of  cementum  shows  at  several  points  greater  thickness,  where  cementum  has 
been  built  up  arounji  fibers  to  attach  the  strong  bands  that  resist  rotation.  D, 
bone  of  the  alveolar  process.  E,  dark  spots  representing  indifferent  fibrous 
tissue  surrounding  and  accompanying  the  blood-vessels  and  nerves,  or 
fibers  which  run  in  a  plane  at  right  angles  to  the  section.  On  the  right  side 
the  fibers  are  seen  passing  from  the  mesial  of  the  lateral  to  the  distal  of  the 
central,  the  septum  of  bone  not  coming  between  at  this  point.  At  the  left 
the  fibers  are  seen  passing  from  the  cementum  to  the  bone  of  the  alveolar 
process. 


ALVEOLUS    AND    PERIDENTAL    MEMBRANE.  55 

him  to  better  comprehend  not  only  the  difficulties  and  possibilities 
in  tooth  movement,  but  as  well  the  anchorage  to  be  gained  from 
teeth  in  the  operation. 

Of  the  seven  possible  tooth  movements  it  is  well  known  that 
depressing  a  tooth  in  its  socket  is  the  most  difficult.  This  is  readily 
explained  from  the  fact  that  by  far  the  largest  number  of  fibers — 
the  suspensory  fibers — directly  resist  the  teeth  in  mastication,  and 
consequently  in  the  movement  of  depression. 

The  next  most  difficult  movement  is  that  of  rotation.  While 
probably  most  of  the  fibers  indirectly  tend  to  prevent  the  tooth 
from  turning  in  its  socket,  there  are  an  unusual  number  at  the 
four  angles  so  arranged  as  to  directly  resist  such  action. 

The  lingual  and  labial  movements,  less  difficult  to  perform,  have 
less  resistance  from  the  fibers,  while  to  the  movement  of  elevation 
very  little  resistance  is  offered  by  the  fibers, — only  by  those  at  the 
extreme  apex  of  the  root, — and  experience  proves  that  this  is  by 
far  the  easiest  movement  to  accomplish. 

Thickness. — The  thickness  of  the  peridental  membrane  varies 
greatly  in  different  periods  of  life,  being  much  thicker  in  child- 
hood and  gradually  becoming  thinner  as  old  age  advances.  This 
is  brought  about  largely  by  the  deposition  of  bone  around  the 
entire  internal  plate  of  the  alveolus,  similar  to  the  lamellar  arrange- 
ment in  the  large  bones.  The  membrane  is  sometimes  further 
encroached  upon  by  increase  in  the  thickness  of  cementum  by 
deposits  by  the  cementoblasts  around  the  ends  of  the  fibers.  This 
becomes  especially  marked  in  that  pathological  condition,  hyper- 
cementosis,  and  is  well  shown  in  Fig.  39. 

Blood  Supply. — The  peridental  membrane  is  freely  supplied  with 
blood,  which  is  derived  from  three  sources : 

First,  from  branches  of  vessels  given  off  from  the  gums. 

Second,  from  numerous  branches  from  the  alveolus. 

Third,  from  one  or  two  large  branches  entering  through  the 
apical  space  and  which  immediately  divide  and  subdivide,  some 
being  given  off  to  the  pulp  and  others  to  the  membrane,  forming 
a  rich  plexus  throughout  these  structures. 

The  advantage  of  these  various  supplies  of  blood  is  apparent, 
for  if  from  disease  or  pressure  the  supply  be  interfered  with  from 
one  source,  that  derived  from  the  remaining  sources  is  still  ample. 

The  question  is  often  asked,  "In  the  rapid  movement  of  teeth 


50  MALOCCLUSION. 

is  the  blood-supply  to  the  pulp  shut  off?"  As  minute  branches  of 
vessels  are  supplied  to  the  pulp  through  the  foramen  from  the  peri- 
dental  membrane,  as  well  as  from  the  large  branch  entering  the 

FIG.  39. 


Transverse  section  of  the  peridental  membrane,  showing  the  fibers  passing 
from  the  cementum  to  the  bone,  taken  from  the  disto-lingual  corner  of 
Fig.  38. 

B,  dentin.  The  light  band  next  the  cementum  shows  the  first  formed  layer, 
or  granular  layer  of  Tomes.  C,  cementum,  showing  two  layers,  the  inner  or 
first  formed  darker  and  more  even  in  thickness ;  the  outer,  or  newer,  lighter, 
and  showing  a  hypertrophy  at  the  disto-lingual  corner,  where  the  cementum 
is  being  built  up  around  the  fibers  to  attach  the  strong  bands  which  resist 
rotation  and  which  are  seen  stretching  across  to  the  bone  of  the  alveolar  pro- 
cess, D.  D,  bone  of  alveolar  process.  F  marks  a  spot  where  absorption  is 
going  on  in  the  bone.  The  small  dark  spots  next  to  the  surface  of  the  bone 
are  osteoclast  cells. 


MODELS THEIR    CONSTRUCTION    AND    STUDY.  57 

apical  space,  it  is  not  probable  that  strangulation  could  result 
unless  preceded  by  inflammation. 

The  vessels  supplying1  the  peridental  membrane,  for  the  most 
part,  are  found  midway  between  the  bone  and  cementum.  In  old 
age,  however,  they  are  found  nearer  to  the  bone,  even  partially 
imbedded  therein,  so  that  their  course  may  often  be  traced  on  the 
surface  of  the  inner  plate. 

When  force  is  exerted  upon  a  tooth  by  the  regulating  appliance, 
as  for  example  in  rotation,  there  is  a  slight  springing  of  the  process, 
and  the  fibers  directly  resisting  the  movement  are  immediately 
placed  on  tension,  which  causes  a  feeling  of  discomfort,  owing  to 
the  pressure  upon  the  nerves  of  the  membrane.  This  gradually 
subsides,  due  probably  at  first  to  the  temporary  partial  paralysis 
of  the  nerves  by  the  pressure,  and  later  to  the  gradual  relinquish- 
rnent  of  the  pressure  by  the  further  movement  of  the  teeth. 

As  a  result  of  this  pressure  a  greater  number  of  the  osteoclasts 
are  developed  and  stimulated  to  activity.  They  immediately  begin 
the  work  of  absorption  of  that  portion  of  the  alveolus  which  offers 
greatest  resistance  to  the  moving  teeth,  as  well  as  dissolving  a 
portion  of  the  bone  and  fibers  which  are  on  greatest  tension.  Such 
a  point  is  well  shown  at  F,  Fig.  39. 

The  cementoblasts  and  osteoblasts  are  also  stimulated  to 
activity,  and  as  soon  as  opportunity  offers  begin  the  work  of  repair, 
depositing  bone  about  the  ends  of  the  fibers  which  have  been 
severed  and  filling  in  bone  in  the  space  made  by  the  moving  tooth. 
As  the  fibers  of  the  membrane  pursue  different  courses  only  a  small 
proportion  of  them  are  on  direct  tension  at  the  same  time,  some 
being  dissolved  while  others  are  being  replaced,  so  that  only  a  por- 
tion of  them  are  detached  at  one  time  unless  the  normal  rate  of  re- 
pair is  interfered  with  by  inflammation  or  a  too  rapid  movement. 


CHAPTER    VI. 

MODELS — THEIR  CONSTRUCTION  AND  STUDY. 

Material  for  Impressions. — In  deciding  upon  a  proper  course  of 
treatment  in  any  given  case,  it  is  of  the  first  importance  to  obtain 
very  accurate  articulating  models  of  both  arches.  Such  models 


58  MALOCCLUSION. 

not  only  assist  us  in  determining  the  variation  from  the  normal  and 
the  class  to  which  the  case  belongs,  but  also  aid  in  deciding  the 
proper  plan  of  treatment,  and  are  exceedingly  valuable  as  refer- 
ences during  its  continuation.  From  such  models  accurate  meas- 
urements may  be  taken  from  time  to  time  for  comparison  with 
the  natural  teeth  on  each  visit  of  the  patient.  In  this  way  one 
may  not  only  judge  of  the  exact  movements  of  the  malposed  teeth, 
but  any  unfavorable  movement  of  the  anchor  teeth  may  be  de- 
tected. 

The  reliability  and  value  of  these  models  is  only  in  proportion 
to  their  accuracy,  and  the  nearest  approach  to  accuracy  is  in  models 
made  from  plaster  impressions.  These  models  must  show  not 
only  both  arches  and  the  relative  positions  of  the  teeth  and  cusps, 
as  well  as  the  vault  of  the  arch,  rugge,  and  gums,  but  must  also 
correctly  show  as  much  of  the  roots  and  positions  of  the  same  as  are 
indicated  by  the  gums  and  alveolar  process  up  to  the  point  where 
the  attachment  of  the  muscles  renders  obscure  the  further  shape 
of  the  jaw. 

It  is  frequently  stated  by  those  writing  on  this  portion  of  the 
subject  that  models  sufficiently  perfect  can  be  made  from  impres- 
sions taken  in  modeling  compound  or  other  of  the  plastics.  There 
is  no  fact  better  known  in  dentistry,  however,  than  that  an  im- 
pression of  the  teeth  made  with  modeling  compound  or  any  of  the 
plastics  can  only  remotely  approach  accuracy  even  where  they  are 
in  normal  position. 

The  shape  of  the  jaw,  together  with  the  shapes  and  inclinations 
of  the  teeth,  make  the  removal  of  a  plastic  impression,  without 
change  of  form,  impossible.  The  degree  to  which  arrest  of  de- 
velopment of  the  alveolus  has  taken  place,  especially  in  the  region 
of  the  roots  of  the  incisors,  so  important  to  accurately  record  in  the 
model,  can  only  be  the  merest  supposition  in  a  model  made  from 
a  plastic  impression. 

From  the  large  number  of  models  of  this  kind  which  the  author 
receives  each  year  from  dentists,  none  of  which  have  even  ap- 
proached accuracy,  it  is  evident  that  the  value  of  correct  models  is 
not  sufficiently  appreciated. 

It  is  quite  probable  that  those  who  object  to  plaster  impressions 
have  never  taken  the  time  to  properly  learn  the  correct  method 
of  taking  them,  otherwise  they  would  find  but  little,  if  any,  more 


MODELS THEIR    CONSTRUCTION    AND    STUDY.  59 

trouble  to  themselves,  or  objection  from  the  patient,  than  if  one 
of  the  plastics  were  used. 

Method  of  Taking  Impressions. — If  the  reader  will  carefully  ob- 
serve the  following  simple  plan  for  taking  impressions  and  making 
models  he  will  find,  after  a  little  experience,  that  the  method  is  easy 
and  the  most  perfect  results  certain.  He  must,  however,  observe 
extreme  care  and  accuracy  in  each  stage  of  the  operation.  We 
may  as  well  remark  here  that  a  careless  operator  could  never  hope 
to  be  successful,  and  had  better  remain  content  with  the  unreliable 
results  of  plastics. 

First,  the  teeth  should  be  thoroughly  cleansed  from  all  tartar  or 
soft  deposits.  For  this  the  little  soft-rubber  cup  disk,  used  with 
pumice,  is  excellent.  Care  should  be  taken  not  to  wound  the  gums, 
as  any  bleeding  prevents  sharpness  in  the  outline  of  the  gingiva. 

The  Trays. — The  trays  shown  at  Fig.  40  are  essential.  There 
are  five  sizes.  They  were  especially  designed  by  the  author,  in 
accordance  with  the  anatomy  of  the  parts,  for  taking  impressions 
of  complete  or  partial  dentures,  the  rims  and  vaults  being  much 
higher  than  in  the  ordinary  trays,  which  were  all  designed  for  tak- 
ing impressions  of  edentulous  jaws.  It  is  very  important  that  they 
should  always  be  kept  thoroughly  smooth,  bright,  and  clean. 
When  not  in  use  they  should  be  wrapped  in  clean  cotton  flannel, 
to  prevent  marring  by  contact  with  each  other. 

In  taking  an  impression  care  should  be  observed  to  select  a  suf- 
ficiently large  tray,  which  should  be  bent  to  conform  more  per- 
fectly to  any  peculiarity  in  the  shape  of  the  jaw.  This  will  not 
injure  the  tray.  The  proper  size  and  shape  will  be  best  determined 
by  trials  in  the  mouth. 

Taking  the  Upper  Impression. — Good  impression  plaster  is  mixed 
in  the  usual  way  and  carefully  distributed,  as  shown  in  Fig.  41,  the 
shape  and  height  of  the  trays  making  but  little  impression  material 
necessary.  It  will  be  observed  that  the  greater  amount  is  placed 
in  the  anterior  part  of  the  tray  and  made  to  extend  over  the  outer 
edge  of  the  rim,  none  being  allowed  in  the  vault  of  the  tray. 

It  is  now  placed  squarely  in  position  and  the  plaster  allowed 
to  rest  evenly  in  contact  with  the  occlusal  edges  of  all  the  teeth, 
but  not  to  be  forced  up  into  position.  The  lip  is  then  raised  and  the 
plaster  extending  outside  of  the  rim  of  the  tray  is  carried  high  up 
underneath  it  with  the  finger;  this  is  to  insure  expulsion  of  air,  as 


6o 


MALOCCLUSION. 

FIG.  40. 


MODELS THEIR    CONSTRUCTION    AND    STUDY.  6l 

well  as  a  high  impression.  The  tray  is  then  forced  up  evenly  until 
the  points  of  the  teeth  touch,  or  nearly  touch,  the  bottom  of  the 
tray,  and  steadily  supported  upon  the  end  of  the  index  finger  only. 
To  expel  the  air  from  the  cheeks  they  are  now  gently  manipulated, 
but  not  drawn  down,  as  to  do  this  would 'expel  a  portion  of  the 
plaster  and  prevent  one  of  the  important  objects, — viz,  a  very  high 
and  accurate  impression. 

There  being  no  surplus  plaster  in  the  vault  of  the  tray,  little, 
if  any,  can  be  forced  in  contact  with  the  soft  palate,  to  cause  nausea. 
The  patient  will  therefore  not  be  inconvenienced  and  the  impres- 
sion may  be  allowed  to  remain  until  it  has  become  thoroughly  set, 
which  is  very  important,  as  the  harder  the  plaster  is  allowed  to  be- 
come the  more  perfect  will  be  the  impression.  If  removed  too 
quickly  a  film  of  the  plaster  will  be  found  adhering  to  the  surfaces 
of  the  teeth. 

The  tray  must  now  be  loosened  and  taken  away,  leaving  the 
impression  in  the  mouth.  It  is  essential  that  the  tray  should  loosen 
easily  from  the  impression,  hence  the  importance  of  its  being  kept 
clean,  bright,  and  smooth. 

Removing  the  Upper  Impression. — All  superfluous  pieces  should 
be  carefully  removed  with  a  pair  of  pliers,  and  the  saliva  and  re- 
maining soft  portions  should  be  thoroughly  removed  by  means  of 
numerous  pledgets  of  cotton  of  generous  size. 

Two  grooves  are  then  scraped  or  cut  in  the  hardened  plaster  on 
a  line  parallel  with  the  cuspid  teeth,  but  should  not,  however,  be 
cut  quite  through.  Then  with  a  quick  pry  with  the  point  of  a  pen- 
knife the  anterior  plate  is  loosened  and  laid,  together  with  all  sub- 
sequent pieces,  on  a  clean  blotting  pad.  The  lateral  pieces  are 
then  broken  off  with  the  thumb  and  finger,  when  the  large  piece 
covering  the  roof  of  the  mouth  alone  will  remain.  This  may  be 
readily  worked  loose,  and  if  the  operation  has  been  carefully  per- 
formed the  impression  will  consist  of  four  pieces  (although  to  have 
a  much  greater  number  would  in  no  way  injure  it).  Great  care 
should  be  observed  to  save  all  small  pieces,  having  them  as  clean 
as  possible,  and  to  immediately  place  them  near  their  original  posi- 
tions in  the  large  pieces. 

Uniting  the  Pieces  of  the  Upper  Impression. — After  removing  the 
pieces  of  the  impression,  they  should  be  laid  away  and  thoroughly 
dried  before  uniting. 


62 


MALOCCLUSION. 


Patience  and  care  should  be  exercised  in  uniting  the  pieces.  If 
skillfully  done,  the  line  of  fracture  can  hardly  be  detected.  The 
pieces  are  best  united  by  means  of  wax  made  quite  hot  on  the 
spatula  and  flowed  over  the  outside,  the  clean,  united  ends  being 
held  so  perfectly  in  contact  that  none  will  flow  into  the  fracture. 
They  should  never  be  united  in  the  tray,  as  accuracy  by  this  method 
is  impossible. 

In  uniting  the  impression  the  smaller  pieces  should  first  be 
joined  to  the  larger,  instead  of  attempting  to  force  them  into  correct 

FIG.  42. 


position  after  union  of  the  large  pieces.  The  minute  pieces  are 
best  held  in  position  with  celluloid  cement.* 

In  uniting  the  pieces  they  should  be  placed  in  actual  contact  only 
once,  and  immediately  secured.  The  habit  of  frequently  trying 
pieces  together  should  be  avoided,  as  the  fine  serrations  are  thus 
destroyed. 

This  method  of  taking  impressions  preserves  the  fine  points  of 

*Pieces  of  ordinary  celluloid  plates  dissolved  in  equal  parts  commercial 
ether  and  strong  alcohol. 


MODELS THEIR    CONSTRUCTION    AND   STUDY.  63 

the  interdental  spaces.     We  believe  it  to  be  the  only  practicable 
way  of  taking  an  impression. 

After  the  impression  is  united  it  should  present  the  appearance 
illustrated  in  Fig.  42. 

Taking  the  Lower  Impression. — In  like  manner  the  impression 
of  the  lower  arch  is  secured,  being  carefvil  to  observe  the  essential 
points, — namely,  carrying  the  impression  material  which  has  been 
built  up  and  outside  of  the  anterior  part  of  the  rim  of  the  tray,  well 
down  beneath  the  lip  i^ith  the  finger  before  forcing  the  tray  home, 
then  expelling  the  air  by  gradually  working  the  cheeks  while  the 
tray  is  steadily  held  by  the  ends  of  two  fingers  of  the  left  hand,  one 
to  rest  on  the  top  of  each  lateral  half.  The  handles  of  the  trays  are 
only  used  for  insertion  and  removal  of  the  tray. 

While  thus  supported  the  folding  in  of  the  cheeks  between  the 
gums  and  distal  portion  of  the  tray  should  be  guarded  against  by 
gently  forcing  them  outward  and  backward  with  the  ringer. 

To  guard  against  the  infolding  of  the  tongue  it  should  be  raised 
and  gently  drawn  forward,  then  allowed  to  settle  back  into  an 
easy  position. 

Removing  the  Lower  Impression. — In  removing  the  lower  impres- 
sion, in  addition  to  the  labial  grooves  parallel  with  the  cuspids,  it 
is  often  desirable  to  make  two  other  grooves  in  the  plaster  parallel 
with  the  lingual  surfaces  of  the  cuspids  Sometimes  a  single 
groove  between  the  central  incisors  will  be  sufficient.  The  exact 
number  and  location  of  grooves  in  both  impressions  should  vary 
according  to  the  requirements  of  the  irregularities,  and  should  be 
carefully  planned  before  inserting  the  impression  material. 

Removing  Impressions  from  Arches  with  Spaces,  due  to  Loss 
of  Teeth. — In  the  case  of  an  impression  where  one  or  more  of  the 
teeth  are  missing,  the  difficulty  of  removing  it  by  ordinary  methods 
is  greatly  increased.  There  are  two  plans,  however,  by  which  this 
difficulty  can  be  easily  overcome  and  accurate  impressions  of  the 
most  difficult  partial  dentures  secured. 

The  first  is  by  cutting  a  deep  additional  groove  in  the  impres- 
sion mesio-distally  between  the  nearest  points  of  the  adjoining 
teeth.  The  lateral  halves  of  the  segment  are  then  readily  sprung 
apart  and  the  pieces  dislodged.  The  peculiarities  of  these  spaces 
should  be  carefully  studied  before  inserting  the  impression  in  the 
mouth. 


64  MALOCCLUSION. 

Another  excellent  plan  for  weakening  the  impression  at  ex; 
the  same  points  is  to  insert  a  piece  of  thin  metal  or  tough  c 
board  in  the  space  of  the  missing  teeth,  the  pieces  being  held  by 
nearest  approximal  surfaces  of  the  teeth  at  either  end ;  the  lo 
edge  resting  upon  the  gum,  while  the  upper  edge  should  be  c 
line  about  parallel  with  the  occlusal  surfaces  of  the  teeth.  By 
method  grooving  will  be  nearly  or  quite  unnecessary. 

Varnishing  the  Impression.— The  impressions  being  united  ; 
thoroughly  dried,  they  should  be  coated  with  shellac  varnish ; 
the  expiration  of  half  an  hour,  or  when  the  varnish  shall  have 
come  hard,  a  second  coat  should  be  applied  over  the  tooth-surfa> 
only,  avoiding  the  gum  surface  in  front.     Dry  again  thorough 
and  then  apply  over  the  entire  impression,  with  the  exception  of  the 
gums  of  the  incisors  and  cuspids,  an  even  coat  of  sandarac  varnisl 

Pouring  the  Model. — After  drying  for  half  an  hour  the  impre 
sion  will  be  ready  for  filling,  which  may  be  best  accomplished,  in 
order  to  insure  expulsion  of  air-bubbles,  by  quickly  and  careful 
painting  the  plaster  into  the  tooth-cavities  with  a  small  camel's-ha 
brush,  then  rapidly  filling  with  a  spatula,  gently  shaking  the  whi 
(never  jarring)  ;  after  which  it  should  be  turned  bottom  upwat 
on  a  glass  slab. 

Separating  the  Model. — After  the  plaster  shall  have  thoroughl 
set,  the  pieces  of  the  impression  may  usually  be  very  readily  sepa 
rated  in  the  same  order  in  which  they  were  removed  from  th 
mouth.     Should  any  air  cavities  be  found  in  the  model  they  ma 
be  filled  by  packing  in  white  oxyphosphate  of  zinc  and  pressin; 
it  home  by  replacing  the  corresponding  piece  of  the  impressic.i 
which  should  be  allowed  to  remain  until  the  cement  is  thoroughl; 
hardened,   when   it   will   readily   separate,   leaving  a   very   perfec 
surface.     A  cusp  or  broken  tooth  may  in  like  manner  be  repaired 
or  these  defects  may  be  remedied  by  the  artistic  use  of  a  delicate 
brush  in  the  application  of  plaster  of  a  creamy  consistence. 

The  models  may  now7  be  trimmed ;  and  not  only  will  there  be  a 
surface  as  smooth  as  polished  marble,  but  each  cusp,  all  the  inter- 

*It  is  important  that  both  of  these  varnishes  shall  be  of  the  proper  con- 
sistence, which  is  difficult  to  describe.  If  too  thin  the  hard,  glossy  surface 
will  be  wanting,  and  it  will  be  difficult  to  separate  the  impression  without 
injury  to  the  model.  If  too  thick  all  fine  tracings  of  the  impression  will 
be  obliterated. 


MODELS THEIR    CONSTRUCTION    AND    STUDY.  65 

dental  spaces,  and  the  rugae,  as  well  as  the  inclinations  of  the  roots, 
and  even  the  minute  "stipples"  of  the  gum  and  the  developmental 
lines  of  the  enamel,  will  all  be  accurately  and  beautifully  shown. 
Any  coating  of  paint  or  varnish  only  detracts  from  the  beauty  of 
such  models. 

FIG.  43. 


I 


lit!-.:'*     *  ...     '•«*H»*I 


»  mm-m  mmmmm 
mmmmmmmm 


mmmmmmmmmm 


mmmmmmmmmm 


mmmmmmmmmm 
mmmmmmmmmm 


mmmmmmmmmm 


mmmmmmmmmm 
mmmmmmmmmm 
******* ff 91 


mmmmmmmimmm 
mmmmmmmmmm 

mmmmmmmmmm 


They  should  now  be  carefully  articulated  after  comparison  with 
the  natural  teeth,  and  the  articulation  indicated  by  two  or  more 
pencil  markings,  so  the  proper  points  of  contact  may  afterward 
be  readily  found.  These  serve  the  purpose  much  better  than  any 
form  of  an  articulator.  The  models  should  also  be  neatly  labeled 
and  placed  in  a  suitable  cabinet,  for  protection  from  dust  and  injury. 

6 


66  MALOCCLUSION. 

to  serve  for  study  and  reference,  and,  on  occasion,  be  valuable  as 
legal  evidence.  Fig.  43  shows  a  very  convenient  form  of  case 
designed  by  the  author  for  this  special  purpose. 

As  soon  as  the  teeth  have  been  completely  moved,  another  impres- 
sion should  be  taken  and  models  made.  This  is  done  after  all 
appliances  have  been  removed  and  the  teeth  thoroughly  cleansed, 
and  immediately  previous  to  adjusting  the  retaining  devices.  These 
models  are  valuable  for  comparison  with  the  natural  teeth  during 
the  period  of  retention,  as  well  as  for  future  reference. 

It  is  also  of  advantage  to  have  "study  models"  occasionally  made 
during  treatment  and  retention  by  pressing  a  piece  of  softened 
wax,  about  three-eighths  of  an  inch  deep,  onto  the  occlusal  edges 
of  the  teeth,  to  accurately  show  their  positions  and  such  appliances 
as  may  be  upon  them  only. 

Value  of  Good  Models. — A  collection  of  fine  accurate  models  is 
not  only  an  incentive  to  keener  interest  and  better  work,  but  is  a 
most  valuable  form  of  "library"  in  itself,  in  which  many  valuable 
phases  of  the  subject  are  recorded  which  can  never  be  reduced  to 
writing. , 

Models  should  never)  be  mutilated  by  the  fitting  of  bands  and 
appliances.  While  they  may  serve  as  a  basis  for  general  measure- 
ments for  the  appliances,  yet  the  fitting  should  always  be  done  to 
the  natural  teeth. 

Photographs  of  Patients. — As  one  of  the  principal  objects  of  the 
correction  of  malocclusion  is  to  improve  the  facial  lines  of  the 
patient,  it  is  quite  as  important  that  accurate  photographs  of  the 
patient  be  secured  before  treatment  is  begun,  as  well  as  at  its  com- 
pletion. 

By  occasional  careful  comparisons  of  the  original  photographs 
with  the  face  of  the  patient  during  the  progress  of  treatment,  a 
better  understanding  of  the  true  conditions  of  the  case,  as  well  as 
much  valuable  knowledge  in  facial  art,  will  be  gained. 

In  photographing  the  patient  should  sit  in  the  easiest  and  most 
natural  position,  with  the  jaws  lightly  closed  and  teeth  in  natural 
occlusion.  One  full  profile  and  one  full  front  view  of  the  face 
should  be  obtained.  From  such  negatives  numerous  blue  prints 
may  be  easily  made  at  slight  expense. 


REGULATING    APPLIANCES PRELIMINARY    CONSIDERATIONS.         6? 

CHAPTER    VII. 

REGULATING    APPLIANCES PRELIMINARY    CONSIDERATIONS. 

REGULATING  appliances  are  devices  for  exerting  pressure  upon 
malposed  teeth  in  order  to  place  them  in  harmony  with  the  line  of 
occlusion. 

Two  plans  are  now  followed  in  the  designing  and  construction 
of  regulating  appliances,  the  first  acting  upon  the  belief  that  each 
case  so  radically  differs  from  all  others  that  an  appliance  must  be 
invented  and  constructed  from  raw  material  to  meet  its  special 
requirements.  The  second  plan  recognizes  the  division  of  mal- 
occlusion  into  a  few  clearly-defined  classes,  having  requirements 
of  treatment  clearly  indicated,  with  fixed,  standard  forms  of  ready- 
made  regulating  appliances  acting  upon  definite  principles,  which 
amply  provide  for  all  requirements  of  all  cases  belonging  to  each 
class. 

The  first  plan  is  the  one  which  has  been  most  universally  em- 
ployed, and  has  come  down  to  us  from  the  earliest  history  of  ortho- 
dontia;  indeed,  much  of  the  literature  of  the  science  consists  of 
descriptions  of  appliances  which  have  been  invented  to  accomplish 
tooth-movements  in  special  cases,  until  some  thousands  are  re- 
corded, one  author  alone  boasting  of  many  hundred.  Where  much 
may  be  accomplished  in  the  following  of  this  plan,  in  devising  and 
constructing  appliances,  yet  it  should  require  no  argument  to  prove 
that  there  are  many  reasons  why  the  plan  is  most  defective  and 
unscientific.  First,  it  necessitates  that  each  dentist  shall  be  an 
inventor,  and  it  is  well  known  that  the  inventive  faculty  is  rather 
a  natural  gift  than  an  acquirement,  and  can  be  exercised  success- 
fully only  by  a  very  few.  As  all  inventions,  if  perfected,  must  be 
experimented  with,  it  must  follow  that  each  case  so  treated  must  be 
largely  in  the  nature  of  an  experiment,  often  necessitating  many 
changes  in  the  plan  and  construction  of  appliances.  Hence  all 
treatment  upon  such  theory  must  be,  and,  in  fact,  has  ever  been, 
tedious  and  costly,  and  often  of  doubtful  result. 

Second,  another  objection  is  that,  following  this  plan,  the  con- 
struction of  appliances  must  necessarily  be  more  or  less  crude  and 
lacking  in  requisite  proportions,  for  any  instrument  only  reaches 


68  MALOCCLVSIOX. 

perfection  as  to  size,  proportion,  temper,  strength,  and  finish  after 
much  experimenting  and  repeated  efforts  toward  perfection  in 
manufacture. 

Finally,  another  objection,  more  serious  than  all,  is  that,  as  the 
plan  is  empirical,  with  only  a  vague  and  indefinite  basis  from  which 
to  reason,  the  difficulties  in  teaching  and  practice  become  very- 
great  and  the  results  greatly  limited.  After  a  life  of  practice  the 
dentist  following  this  plan  must  still  be  in  a  maze  of  experiments, 
and  unable  to  impart  information  that  could  be  of  much  assistance 
to  those  who  may  begin  the  practice  after  him.  This,  we  think,  is 
abundantly  proven  by  some  of  the  elaborate  works  which  have 
recently  been  written  on  the  subject. 

Such  teachings  may  be  said  to  "begin  nowhere  and  end  nowhere,"" 
and  the  attempted  correction  of  malocclusion  with  such  appliances 
has  been  most  appropriately  termed  "tinker  regulating." 

The  second  plan,  as  we  have  already  stated,  recognizes  the  practi- 
cability of  fixed,  standard  forms  of  devices  for  the  requirements  of 
tooth  movement  necessary  in  all  the  various  classes  of  malocclusion,. 
the  proper  forms  having  been,  arrived  at  as  a  result  of  careful  ex- 
perimentation and  close  observation  in  a  very  large  number  of 
cases,  embracing  the  greatest  variety  of  malocclusion.  Instead  of 
hand-made  productions  by  the  dentist,  which,  with  his  limited 
experience  and  meager  facilities,  must  always  fall  far  short  of  the 
ideal  in  delicacy  of  proportion,  temper,  accuracy  of  fit,  and  inter- 
changeability  of  parts  and  in  finish,  they,  like  fine  watches,  are  made 
upon  elaborate  machinery  by  the  most  skillful  workmen,  who  have 
become  experts,  not  only  through  natural  ability,  but  from  close 
study  and  long  practice,  insuring  the  most  perfect  product  at  the 
minimum  of  expense. 

Dr.  Farrar  long  ago  predicted  the  possibility  of  this  plan,  for  he 
says  in  Vol.  XX,  page  20,  of  the  Dental  Cosmos, — 

"It  has  for  some  time  been  evident  to  me  (though  by  most  people- 
thought  to  be  impracticable)  that  the  time  will  come  when  the 
regulating  process  and  the  necessary  apparatus  will  be  so  systema- 
tized and  simplified  that  the  latter  will  actually  be  kept  in  stock,  in 
parts  and  wholes,  at  dental  depots  in  readiness  for  the  profession- 
at  large,  so  that  it  may  be  ordered  by  catalogued  numbers  to  suit 
the  needs  of  the  case ;  so  that  by  a  few  moments'  work  at  the  blow- 
pipe in  the  laboratory  the  dentist  may  be  able,  by  uniting  the  parts,. 


REGULATING    APPLIANCES PRELIMINARY    CONSIDERATIONS.         69 

to  produce  any  apparatus,  of  any  size  desired,  at  minimum  cost  of 
time  and  money." 

If  such  appliances  are  practicable,  it  must  become  apparent  to  all 
thoughtful  minds  that  the  advantages  from  their  use  must  be  very 
great  over  the  first  plan,  for,  instead  of  being  confronted  with  a 
confusing  and  almost  limitless  number  of  devices,  which  can  at 
best  serve  only  as  general,  vague,  and  often  delusive  patterns  to 
him,  the  dentist  has  but  to  thoroughly  familiarize  himself  with  a 
few  standard  devices  and  their  combinations,  which  he  may  ever 
keep  in  stock  in  readiness  for  immediate  demands,  and  which  may 
be  quickly  and  easily  applied,  thus  obviating  the  great  disadvantage 
of  delays,  so  often  necessary  in  the  former  plan. 

Again,  familiarity  with  and  repeated  use  of  the  standard  appli- 
ances adds  greatly  to  the  possibilities  of  development  of  skill  and 
judgment  in  their  use,  as  in  the  case  of  the  frequent  use  of  favorite 
patterns  of  pluggers  or  excavators. 

Finally,  instead  of  being  compelled  to  puzzle  himself  in  invent- 
ing and  experimenting  until  a  suitable  and  efficient  instrument  has 
been  devised,  he  has  the  advantage  of  being  able  to  thoroughly 
rely  upon  standard  forms  of  devices,  as  he  should,  and  as  he  does 
in  other  operations  of  dentistry  and  surgery.  He  is  thus  enabled 
to  direct  his  energies  to  a  more  thorough  and  intelligent  study  of 
the  case  in  hand,  such  as  the  problems  of  occlusion,  art  relations, 
anchorage,  retention,  physiology,  etiology,  etc.,  the  consideration 
of  which  is  too  often  sacrificed  for  the  problem  of  devising  and 
constructing  of  appliances.  And  whether  or  not  ideal  standard 
regulating  appliances  have  yet  been  reached,  the  possibilities  and 
positive  advantages  of  the  principle  over  the  first  plan  are  so  marked 
that  we  think  all  teachers  who  are  interested  in  this  branch  should 
make  efforts  toward  that  direction,  rather  than  assisting  in  per- 
petuating a  principle  which  is  so  obviously  defective  that  it  must 
be  apparent  to  all  that  it  is  a  positive  hindrance  to  the  real  progress 
of  orthodontia. 

In  no  other  branch  of  medicine,  nor  in  any  other  science  that  we 
know  of,  is  there  such  inclination  to  perpetuate  this  fossilized 
principle.  Even  machinists  deem  it  no  longer  worth  their  while 
to  make  the  tools  they  use.  Then  imagine  a  modern  surgeon 
teaching  his  students  to  invent,  forge,  and  construct  from  raw 
material  instruments  for  each  operation,  or  an  up-to-date  dentist 


/O  MALOCCLUSION. 

grinding  the  clays  and  pigments  for  the  artificial  teeth  he  shall  use, 
or  "designing  and  forging  a  special  instrument  for  each  case  or 
operation."  Such  was  once  the  practice,  but  it  is  now  well  known 
that  most  real  progress  that  has  been  made  in  dentistry  or  surgery 
has  been  since  the  dentist  or  surgeon  was  relieved  of  this  impracti- 
cal task  by  experts,  who  have  produced  instruments  so  perfect  in 
design,  construction,  and  finish  as  to  be  often  even  far  in  advance 
of  his  comprehension  and  skill.  A  few  of  the  writers  and  teachers, 
it  is  true,  are  still  linking  the  present  with  the  past  in  commending 
to  dental  students  the  acquirement  of  skill  in  the  construction  of 
implements  and  appliances,  but  the  custom  is  archaic  and  illogical ; 
and  the  long,  tedious  hours  which  students  are  usually  compelled 
to  devote  to  the  making  of  regulating  appliances,  crude  at  best, 
should  be  directed  by  a  more  advanced  standard  of  teaching  to 
purposes  more  in  keeping  with  the  modern  requirements  of  ortho- 
dontia.  It  is  the  author's  opinion  that,  while  the  practice  of  den- 
tistry involves  the  exercise  of  mechanical  skill,  the  dentist  should 
feel  no  pride  in  classing  himself  as  a  mechanic.  Let  us  hope  that 
the  day  is  forever  past  when  every  man  shall  be  his  own  shoe-  and 
garment-maker. 

The  author's  regulating  appliances,  the  description,  plan  of  appli- 
cation, and  operation  of  which  will  be  given  farther  on,  are  in 
direct  keeping  with  the  second  plan  just  described.  In  fact,  the 
second  plan  may  be. said  to  have  originated  in  the  introduction  of 
this  system  some  fourteen  years  ago.  The  author's  appliances  are 
now  extensively  used  in  all  countries  where  dentistry  is  practiced, 
and  their  efficiency  and  universal  application  are  recognized.  Like 
most  valuable  and  popular  pieces  of  mechanism,  they  have  numer- 
ous imitations,  but  if  intelligent  comparison  be  made  with  all  others 
from  the  basis  of  efficiency,  simplicity,  and  delicacy,  their  supe- 
riority is  at  once  apparent. 

Epochs  in  the  History. — To  the  real  student  of  orthodontia  the 
history  of  regulating  appliances  is  a  most  interesting  and  instruc- 
tive study.  It  shows  that  their  beginnings,  like  those  of  other 
sciences,  were  crude ;  the  unfolding  slow,  and  ofttimes  marked  by 
steps  backward  as  well  as  forward,  with  the  perpetuation  of  much, 
even  into  the  present,  which  should  have  been  left  far  behind. 

Of  necessity,  the  history  of  appliances  is  closely  associated  with 
the  history  of  the  science,  and  measures  its  progress  to  a  consider- 


REGULATING    APPLIANCES PRELIMINARY    CONSIDERATIONS.          /I 

able  extent,  clearly  telling  of  the  apathy  manifested  by  the  profes- 
sion in  general  on  this  subject.  One  surprising  feature  of  the  his- 
tory is  the  frequency  of  rediscovery  of  identical  principles,  their 
materialization  differing  only  in  minutiae  of  manufacture.  While 
the  study  is  of  much  interest  to  the  student  of  orthodontia,  yet  the 
limits  of  this  work  will  not  permit  of  other  treatment  than  the  brief 
mention  of  such  steps  in  the  history  as  may  be  regarded  as  epochs  in 
the  evolution  of  appliances.  This  will  involve  the  consideration 
of  principles  only,  and  of  those  whose  value  is  attested  by  their 
survival  or  present  universality  of  use.  Mere  improvements  in 
methods  of  applying  these  principles,  however  ingenious  and 
valuable,  cannot  here  be  noted.  The  actual  principles  embodied 
are  few. 

The  form  of  the  first  regulating  appliance,  or  by  whom  employed, 
is  not  known.  It  may  have  been,  like  the  substitution  of  the  natural 
by  artificial  teeth,  far  back  in  the  history  of  man,  but  the  first  appli- 
ance which  was  destined  to  mark  a  distinct  step  in  the  written  his- 
tory was  that  given  to  us  by  Fauchard,  of  France,  in  1726,  and 
which  we  will  call  the  expansion  arch,  for  it  is  the  form  of  the  ideal 
arch,  and  its  chief  function  is  to  expand  the  dental  arch,  although 
it  has  been  variously  named  as  bandeau,  bow,  long  band,  bande- 
lette,  etc.  Unquestionably  the  conception  of  this  device  was  the 
one  greatest  step  in  the  invention  of  appliances. 

That  which  may  easily  take  rank  as  second  in  importance  was  the 
invention  of  the  band  for  the  attachment  of  appliances  to  the  teeth. 
Of  bands  there  are  two  kinds,  the  clamp  and  the  plain,  for  different 
uses,  yet  of  equal  importance.  The  first  was  the  invention  of 
J.  M.  A.  Schange,  also  a  Frenchman.  We  find  it  illustrated,  as  in 
Fig.  44,  in  a  book  of  one  hundred  and  eighty  pages  published  in 
Paris  in  1841.*  He  used  it  chiefly  upon  the  malposed  teeth,  rather 
than  for  anchorage.  It  is  only  fair,  however,  that  the  honor  of  the 
invention  should  be  accorded  to  him,  as  its  inception  is  commonly 
thought  to  be  of  later  date.f  It  consisted  of  a  ribbon  of  metal  in 
length  sufficient  to  nearly  encircle  the  crown  of  the  tooth,  each  end 
bent  sharply  at  right  angles,  thickened  and  perforated,  one  threaded, 
the  other  smooth.  A  threaded  shaft  with  perforated  head  was 

*"Precis  sur  le  Redressement  des  Dents."  Par  J.  M.  A.  Schange,  Medi- 
cin-Dentiste,  membre  de  plusieurs  Societes  savantes.  Troisieme  edition. 
Paris,  1841. 

fFarrar,  first  volume. 


72  MALOCCLUSION. 

made  to  engage  the  perforation  in  the  band  shanks.  By  turning 
the  shaft  the  band  was  diminished  in  circumference  and  securely 
clamped  upon  the  crown  to  prevent  displacement,  as  shown  in  the 
engraving,  in  principle  identical  with  Farrar's  of  1876. 

Fie.  44- 


To  all  students  of  orthodontia  another  very  important  epoch  in 
the  history  of  regulating  appliances  should  be  mentioned  in  con- 
nection with  Schange's  clamp  band,  and  also  with  his  improvement 
of  the  expansion  arch,  for  it  is  in  these  connections  that  the  screw 
first  makes  its  appearance  in  regulating  appliances,  the  honor  of 
the  introduction  of  which  has  been  erroneously*  divided  between 
Dwindle,  of  New  York,  and  Gaines,  of  England.  Their  recorded 
dates  of  using  the  screw  were,  however,  eight  years  later  than  that 
of  Schange's. 

The  plain  band  consisted  of  a  ribbon  of  metal  fitted  to  the  cir- 
cumference of  the  crown,  the  ends  being  united  by  brazing. 
Although  such  bands,  of  gold,  were  used  by  the  ancients  for  secur- 
ing artificial  crowns  and  bridges,  it  is  not  clear  by  whom  they  were 
first  used  for  regulating  purposes.  Desirabode  (1726)  speaks  of 
them  as  "bracelets"  or  "little  rings."  Thomas  Evans,  of  Paris, 
again  mentions  them  in  1854,  and  Dr.  A.  H.  Fuller,  in  the  Missouri 
Dental  Journal,  January,  1872,  describes  a  novel  form  of  plain  band. 
It  was  constructed  by  closely  wrapping  a  plaster  model  of  the  tooth 
to  be  banded  with  fine  platinum  wire,  over  which  was  flowed  20- 
carat  gold,  to  which  the  desired  attachments  were  made. 

The  real  value  of  the  plain  band,  however,  dates  from  its  attach- 

*  Farrar,  first  volume. 


REGULATING   APPLIANCES PRELIMINARY    CONSIDERATIONS.         /3 

ment  to  the  tooth  crown  by  means  of  oxychlorid  of  zinc  cement, 
which  was  accomplished  at  about  this  time  by  Dr.  Magill,*  of  Erie, 
Pa.  This  effectually  prevented  its'  displacement  under  the  ordi- 
nary strain  necessary  in  tooth  movement.  Magill's  method  of 
making  the  band  was  to  encircle  the  crown  with  a  thin  ribbon  of 
platinum,  slightly  overlapping  the  ends  and  uniting  by  brazing. 
He  was  probably  not  at  this  time  aware  of  previous  use  of  either 
plain  or  clamp  bands.  By  the  use  of  bands  the  direct,  firm  attach- 
ment of  appliances  to  the  teeth  was  gained,  so  that  loss  of  power  by 
slipping  was  reduced  to  the  minimum,  thus  greatly  increasing  the 
efficiency  of  the  appliances  and  lessening  the  time  necessary  for 
treatment. 

The  regulating  jack-screwf  was  invented  in  1848  by  Dr.  Dwi- 
nelle,  of  New  York.  This  invention  marks  two  important  steps: 
First,  the  introduction  into  orthodontia  of  one  of  the  most  compact, 
yet  powerful,  forms  of  mechanism  for  exerting  force  known  to 
mechanics ;  second,  the  beginning  of  fixed,  standard  forms  of  regu- 
lating appliances  with  interchangeable  parts  and  kept  in  stock  at 
the  dental  supply  houses.  It  consists  of  a  threaded  steel  shaft  with 
conical  head,  perforated  for  the  reception  of  a  turning  tool,  and  a 
rounded  nut,  also  of  steel,  with  long,  parallel  flanges  joined  at  their 
extremities,  which  were  of  fish-tail  form.  Although  difficult  to 
keep  in  position  and  somewhat  expensive,  three  sizes  being  re- 
quired, it  was  at  the  time  regarded  as  a  boon  to  the  profession,  and 
is  still  in  favor  with  many  practitioners. 

Lee  and  Bennett,  some  time  in  the  8o's,  attached  a  washer  of 
elliptical  form  with  perforated  ends  below  the  head  of  the  jack- 
screw,  and,  attaching  ligatures  to  this  and  the  fish-tail,  used  the 
appliance  for  pulling  instead  of  pushing.  The  author's  traction 
screw  was  inspired  by  this  adaptation  of  the  jack-screw,  as  were 
probably  various  other  devices'  that  have  been  used  for  traction. 

*At  the  meeting  of  the  Western  Pennsylvania  Dental  Society,  Pittsburg, 
March,  1896,  in  a  conversation  with  the  author,  Dr.  Magill  said  he  could  not 
remember  the  exact  date  in  which  he  first  began  attaching  the  bands  by 
means  of  cement,  but  believed  it  was  in  1871  or  1872. 

tSome  attempt  has  been  recently  made  to  change  the  name  of  this  appliance 
to  Screw-jack.  But  as  it  has  been  known,  since  1849  as  Jack-screw,  and  is 
defined  in  Webster's  and  the  Standard  dictionaries,  being  illustrated  in  the 
latter  in  position  against  the  teeth,  and  as  the  term  seems  more  appropriate, 
this  innovation  is  not  regarded  with  favor. 


74  MALOCCLUSION. 

The  traction  screw*  may,  in  any  event,  be  regarded  merely  as  a 
modification  of  the  jack-screw,  and  not  as  the  application  of  a 
distinct  principle. 

The  force  derived  from  the  elasticity  of  rubber  has  been  exten- 
sively used  in  tooth  movement.  It  was  introduced  by  Dr.  E.  A. 
Tucker,  of  Boston,  in  1846.  Although  an  immense  amount  of 
harm  has  resulted  from  its  improper  application,  and  it  is  now  far 
less  commonly  used  than  formerly,  yet  it  is,  and  doubtless  will  long 
remain,  a  valuable  adjunct  to  regulating  appliances  under  suitable 
conditions. 

The  application  of  force  for  the  reduction  of  protruding  anterior 
teeth,  gained  through  occipital  anchorage  by  means  of  the  use  of 
the  head-gear,  which  originated  with  Dr.  Norman  W.  Kingsley,  of 
New  York,  in  1866,  was  the  introduction  of  a  principle  of  much 
value. 

The  introduction  of  piano-wire  by  Dr.  Seldon  Coffin,  of  England, 
some  forty  years  ago,  marked  another  step  in  regulating  appliances. 
On  account  of  its  great  elasticity,  it  has  been  extensively  used,  but 
far  less  now  than  formerly,  as  it  has  been  largely  supplanted  by 
German  silver. 

The  introduction  of  vulcanite  for  the  construction  of  regulating 
plates  records,  in  the  author's  opinion,  a  step  of  doubtful  value,  for 
the  reason  that  the  same  results  by  means  of  far  more  delicate  forms 
in  metal  were  previously  accomplished. 

The  introduction  of  tubes f  by  the  author,  in  1886,  may,  we  hope 
not  immodestly,  be  said  to  have  been  another  step  in  the  evolution 
of  appliances,  as  it  provided  a  ready  means  of  attachment  between 
bands  and  working  appliances  which  greatly  simplify  the  neces- 
sary operations.  The  tubes  were  cut  in  desired  lengths  from  a 
crude  form  of  unbrazed  tubing  known  as  joint  wire,  composed  of  a 
silver  alloy ;  but  far  more  suitable'  tubes,  of  special  manufacture, 
are  now  employed.  The  measure  of  value  attributable  to  this  in- 
vention may  be  determined  by  the  reader  upon  observation  of  the 
various  appliances  shown  in  the  literature  since  its  advent.  It 

*This  has  been  denominated  "drag-screw,"  but  the  name  seems  neither  so 
appropriate  nor  euphonious  as  the  other,  and  has  not  been  adopted. 

tTransactions  of  the  Minneapolis  Dental  Society,  December,  1886,  of  the 
Minnesota  State  Dental  Society,  May,  1887,  and  of  the  International  Medical 
Congress,  September,  1887.  Also  Ohio  Dental  Journal,  October,  1887. 


REGULATLNG    APPLIANCES PRELIMINARY    CONSIDERATIONS.          75 

seems  to  have  entered  into  the  formation  of  all  appliances  of  note, 
and  has  a  varied  application. 

In  1886  the  author  made  an  attempt  to  group  all  necessary  regu- 
lating and  retaining  appliances  into  a  simple,  yet  complete,  system, 
with  interchangeable  parts  admitting  of  ready  combination.  This 
system  has  been  gradually  improved,  until  it  is  believed  that  now  it 
is  very  nearly  perfect.  The  advent  of  a  complete  system  is  of  such 
great  importance  in  comparison  with  the  hitherto  fragmentary 
methods,  that  it  is  believed  it  is  worthy  the  distinction  of  being 
classed  among  the  epochs  in  the  history  of  regulating  appliances. 

The  introduction  of  German  silver  (the  valuable  properties  of 
which  are  more  fully  discussed  elsewhere)  by  the  author  in  1887* 
for  the  manufacture  of  regulating  appliances  has  to  such  a  large 
extent  revolutionized  their  manufacture  that  it  must  take  rank  as 
an  important  step  in  their  history. 

The  introduction  of  soft  brass  wire  for  ligatures  is  of  such  great 
practical  value  that  the  author  believes  it  should  here  have  honor- 
able mention. 

REQUISITE  QUALIFICATIONS  OF  APPLIANCES. 

Efficiency. — As  the  object  of  the  regulating  appliance  is  to  per- 
form tooth  movement,  efficiency  should  precede  in  importance  all 
other  qualities.  The  reason  for  this  is  obvious,  for  at  best  the 
correction  of  malocclusion  is  to  a  greater  or  less  degree  an  un- 
pleasant and  protracted  operation ;  and  unless  the  appliance  be 
efficient,  so  that  the  various  tooth  movements  may  be  accomplished 
as  rapidly  as  is  consistent  with  the  physiology  of  tooth  movement, 
the  operation  will  be  unnecessarily  long  and  tedious,  sacrificing 
valuable  time  of  both  patient  and  operator,  and  frequently  leading 
to  discouragement  and  failure. 

A  very  large  number  of  the  appliances  recorded  in  the  literature 
are  so  obviously  defective  in  plan  of  operation,  application  of  force, 
and  anchorage,  as  wrell  as  in  construction,  proportion  of  parts,  and 
manner  of  attachment,  that  the  period  of  wearing  must  necessarily 
have  been  extended  to  many  times  what  would  have  been  necessary 
had  they  possessed  the  requisites  of  truly  efficient  appliances. 

Simplicity. — Next   to   efficiency   in   importance,   the   regulating 

Archives  of  Dentistry,  September,  1888. 


76  MALOCCLUSION. 

appliance  should  be  simple  in  form  and  plan  of  operation.  It  is 
well  known  that  the  best  forms  of  mechanism  are  those  freest 
from  complication,  simplest  in  design,  and  most  direct  in  application 
of  force. 

It  is  also  known  that  most  valuable  machines  possessed  but 
limited  utility  until  they  had  passed  through  certain  evolution- 
ary stages,  in  which  the  original  plans  of  greater  complexity 
gradually  gave  place  to  those  of  simpler  principles.  For  example, 
the  electro-magnetic  mallet  and  the  sewing  machine.  In  fact,  many 
modern  inventions  are  but  the  discovery  of  simpler  methods  in  the 
application  of  long-known  principles ;  and  where  complexity  may  be 
admissible  in  some  machines,  as,  for  example,  the  printing  press, 
yet  we  must  remember  that  it  performs  numerous  functions,  and 
the  limits  of  space  and  weight  are  very  broad,  with  the  freest  scope 
for  application  of  mechanical  principles.  But  in  the  regulating 
appliances  the  restrictions  of  the  lips,  cheeks,  tongue,  gums,  and 
occlusion  make  simplicity  and  freedom  from  bulk  of  great  impor- 
tance. 

The  invention  of  a  simple  yet  efficient  machine  is  a  much  greater 
achievement  than  is  the  invention  of  one  that  is  complicated.  It 
should  be  remembered  that  each  additional  piece  composing  a 
regulating  appliance  usually  augments  in  a  more  than  proportionate 
ratio  the  liability  to  derangement,  as  well  as  the  care  and  time 
required  in  its  operation,  the  expense  of  its  construction,  and  the 
inconvenience  to  the  patient.  And  yet  the  complexity  of  design 
and  number  of  parts  of  many  of  the  regulating  appliances  which 
have  come  down  to  us  through  the  literature  are  such  that  it  would 
seem  that  their  originators  must  have  believed  these  qualities  to  be 
of  the  first  importance.  Many  of  these  appliances  are  in  reality 
curiosities,  and  doubtless  in  the  future  will  be  pointed  out  as  such. 
Such  an  appliance  is  shown  in  Fig.  45. 

Delicacy. — An  appliance  which  is  delicate  of  size  and  proportion, 
and  from  which  all  unnecessary  material  has  been  eliminated, 
possesses  such  important  advantages  as  should  be  readily  appre- 
ciated, for  not  only  is  the  annoyance  to  the  patient  often  largely  in 
proportion  to  the  bulk  of  the  appliance,  but  also  in  the  same  pro- 
portion are  the  functions  of  the  mouth  interfered  with. 

Another  disadvantage  from  a  bulky  appliance  is  the  difficulty  of 
cleansing  it.  It  forms  ready  lodgment  for  particles  of  food,  which, 


REGULATING    APPLIANCES PRELIMINARY    CONSIDERATIONS.         // 

at  the  temperature  of  the  mouth,  soon  undergo  fermentation,  ren- 
dering the  breath  most  offensive  and  necessitating  the  frequent 
removal  of  the  appliance  from  the  mouth  (either  by  the  patient  or 
dentist,  according  to  its  plan  of  construction)  for  the  purpose  of 


cleansing.  Thus  the  operation  is  prolonged.  But,  worse  than  all, 
the  relinquishment  and  reapplication  of  pressure  is.  the  principal 
cause  of  pain  in  moving  teeth,  the  alternate  forward  and  backward 
movements  so  interfering  with  the  tissues  involved  as  to  be  the  most 
potent  cause  of  inflammation. 

For  these  reasons  a  skeleton  form  of  appliance,  with  direct, 
stable  attachments  to  the  teeth  by  means  of  the  plain  or  clamp 
bands,  should  invariably  be  used  in  preference  to  devices  in  combi- 
nation with  plates,  a  remarkable  illustration  of  which  is  shown  in 
Fig.  46. 

It  is  not  so  much  a  wonder  that  such  crude,  bulky,  inefficient,  and 
most  uncleanly  appliances  have  been  used  in  the  past,  for  that  was 
but  natural  in  the  evolutionary  stages  through  which  orthodontia 
has  passed ;  but  why  such  devices  should  find  place  in  modern  text- 
books and  be  advocated  by  modern  teachers  is  most  difficult  to 

*Transactions  Ninth  International  Medical  Congress,  Vol.  V,  p.  577. 
Washington,  D.  C,  1887. 


78  MALOCCLUSION. 

comprehend.  The  fact  is,  there  is  no  longer  any  use  for  the  plate 
forms  in  regulating  appliances.  They  are  as  much  out  of  harmony 
with  the  requirements  of  orthodontia  in  its  present  development  as 
would  be  the  Mexican  ox-cart  for  the  uses  of  a  modern  speeding 
sulky. 

FIG.  46.* 


Inconspicuousness. — As  any  devices  upon  the  teeth  attracting 
attention  are,  to  patients  of  sensitive  nature,  a  source  of  more  or 
less  annoyance,  it  is  important  that  the  regulating  appliance  shall 
be  made  as  inconspicuous  as  possible ;  and  yet  we  insist  that  effi- 
ciency in  an  appliance  is  of  so  much  greater  importance  that  it 
should  be  kept  foremost  in  view,  even  though  the  form  of  appliance 
best  suited  to  the  case  be  conspicuous.  The  wearing  of  appliances 
has  in  recent  years  become  so  common  that  it  no  longer  attracts 
such  attention  and  comment  as  formerly. 

The  degree  of  unsightliness  is  increased  largely  by  the  manner 
in  which  a  given  appliance  is  constructed  and  fitted  to  the  teeth. 
If  gracefully  proportioned,  with  skillfully  made  attachments  and 
the  most  perfect  finish  of  parts,  the  appliance,  although  noticeable, 
may  not  be  really  objectionable  in  appearance;  while  if,  as  is  too 
often  the  case,  the  same  form  of  appliance  be  unnecessarily  bulky, 
badly  proportioned,  unskillfully  attached,  with  little  attention  given 
to  finish  of  parts,  its  appearance  is  most  repulsive. 

Stability  of  Attachments.  — No  matter  how  perfect  the  design  and 
construction  of  an  appliance,  if  the  attachments  to  the  anchor  and 
moving  teeth  be  not  such  as  to  insure  its  stability  the  appliance 
becomes  worthless,  for  if  it  slip  or  give  at  the  point  of  anchorage 
or  deliverance  it  will  either  become  entirely  inoperative  or  the  force 
*Essig's  "American  Text-book  of  Prosthetic  Dentistry." 


REGULATING    APPLIANCES PRELIMINARY    CONSIDERATIONS.         79 

will  be  wrongly  directed,  according  as  the  power  may  be  derived 
from  a  screw  or  spring,  thus  prolonging  the  operation  and  sacrific- 
ing the  time  of  both  operator  and  patient,  with  the  added  pain, 
annoyance,  and  expense  necessitated  by  the  removal  and  repair  of 
the  appliance. 

Owing  to  the  slipperiness  and  irregularity  of  the  surfaces  of  the 
teeth,  stability  of  attachment  of  appliances  has  always  been  one  of 
the  problems  of  tooth-regulation.  Since  the  introduction  of  the 
plain  and  clamp  bands,  firmly  cemented  or  clamped  upon  the  teeth, 
as  well  as  the  wire  ligatures,  the  certainty  of  firm,  immovable 
attachments  is  assured,  with  consequent  perfect  control  of  the  ap- 
pliances and  direction  and  intensity  of  force,  making  it  possible  to 
compute  with  considerable  accuracy  the  time  necessary  for  tooth 
movement  in  each  given  case.  The  great  advantages  of  this  form 
of  attachment  have  rendered  practically  obsolete  attachments  by 
means  of  plates,  clasps,  cribs,  etc.,  and  it  again  becomes  difficult  to 
understand  why  such  forms  of  appliances,  with  their  crude  and 
necessarily  unstable  attachments,  should  still  find  advocates. 

Materials  for  Construction. — Gold,  silver,  platinum,  platinous 
gold,  platinous  silver,  iridio-platinum,  platinoid  (so  called),  alumi- 
num, and  several  of  the  baser  metals  and  alloys,  as  brass,  copper, 
aluminum  bronze,  steel,  and  iro'n,  and  also  vulcanized  rubber,  may 
all  be  used  in  the  construction  of  regulating  appliances,  and  each 
possesses  properties  of  more  or  less  value ;  yet,  after  experimenting 
with  all  of  these,  as  well  as  with  several  other  metals  and  alloys, 
the  author  is  thoroughly  convinced  that  the  one  most  nearly  filling 
all  requirements  is  German  silver.* 

Since  being  introduced  for  the  manufacture  of  regulating  appli- 
ances by  the  author,  some  fourteen  years  ago,  it  has  largely  sup- 
planted all  other  metals  for  this  purpose.  Its  great  practical  value 
becomes  more  and  more  apparent  to  the  unprejudiced  practitioner 
as  the  peculiar  working  properties  and  possibilities  of  this  ideal 
material  are  revealed  by  familiarity  of  use.  It  is  very  susceptible 
to  skillful  working,  and  may  be  developed  to  possess  great  strength 
and  rigidity,  as  demanded  by  the  jack  and  traction  screws.  Again, 
it  may  be  given  great  elasticity,  as  required  by  the  expansion  arches. 
Again,  when  properly  annealed,  it  is  very  malleable,  yet  sufficiently 

*German  silver,  or  nickel  silver,  is  an  alloy  of  copper,  nickel,  and  zinc  pre- 
pared in  varying  proportions  according  to  the  use  for  which  it  is  intended. 


8O  MALOCCLUSION. 

rigid  to  give  it  the  excellent  qualities  so  necessary  in  retention  and 
reinforcing  anchorage,  as  exemplified  in  the  wire  G.  But  its  excel- 
lent qualities  are  perhaps  best  shown  in  the  construction  of  the  plain 
bands  to  be  placed  upon  the  teeth  for  securing  the  attachments  of 
the  appliances. 

If  of  proper  quality  and  properly  treated  in  the  manufacture  it 
is  very  soft  and  pliable,  yet  possessing  great  strength.  It  may  be 
drawn  by  the  band-forming  pliers  so  tightly  about  the  tooth  as  to 
conform  to  its  surface  with  great  accuracy  without  tearing,  even 
though  the  thickness  be  but  .003  of  an  inch  (F)  ;  and  yet  it  is  suffi- 
ciently rigid  to  withstand  driving  to  place  upon  the  tooth  with- 
out crimping  or  changing  form  if  care  be  used.  All  this  is  in 
striking  contrast  with  the  properties  of  gold,  platinum,  or  other 
metals  used  in  the  same  thickness  for  this  purpose. 

Its  surfaces  may  be  readily  united  with  solder,  and  its  fusing 
point  is  so  high  that  any  of  the  various  grades  of  gold  or  silver 
solder,  or  even  pure  gold  itself,  may  be  employed,  if  the  proper 
flame  be  used  and  care  be  taken,  without  fear  of  injuring  the  band 
by  overheating. 

So  slow  a  conductor  of  heat  is  it  that  the  excellent  method  of 
soldering*  by  holding  many  of  the  pieces  with  the  fingers  may  be 
employed,  again  in  sharp  contrast  with  any  of  the  other  metals  we 
have  enumerated. 

It  is  susceptible  of  a  high  degree  of  polish,  which  should  always 
be  given  the  band  after  setting,  and  which  in  most  mouths  will 
remain  durable,  often  assuming  a  delicate  bronze-like  color,  pleas- 
ing in  appearance.  The  author  has  known  these  bands  to  be  worn 
for  three  years  with  no  apparent  change.  In  a  small  percentage 
of  mouths,  however,  it  is  true  that  it  does  become  discolored,  even 
to  unsightl.iness.  This  fact  has  given  rise  to  the  only  prejudice 
against  its  use  that  we  know  of,  but  this  objection  seems  trivial  in 
view  of  its  many  points  of  superiority,  which  should  far  outweigh 
it.  If  the  orthodontist  will  insist  upon  a  reasonable  degree  of 
cleanliness  on  the  part  of  the  patient  while  wearing  the  appliances, 
or  will  occasionally  devote  a  moment  or  two  of  attention  to  them 
himself  with  the  soft-rubber  disk  and  pumice,  followed  by  a  bur- 
nisher, there  need  be  no  occasion  for  complaint. 

And,  lastly,  its  inexpensiveness  brings  it  again  in  sharp  contrast 

*Introduced  by  the  author  in  the  first  edition  of  this  work. 


THE  AUTHOR'S  APPLIANCES.  81 

with  gold  and  platinum;  yet  we  insist  that  it  is  its  ideal  character, 
not  its  inexpensiveness,  that  makes  it  so  preferable  for  the  manu- 
facture of  regulating  appliances. 

The  oft-repeated  fallacy  that  gold  is  the  one  suitable  metal  for 
the  construction  of  regulating  appliances  should,  with  many  other 
fossilized  inconsistencies  in  orthodontology,  be  relegated  to  the 
past,  for  unquestionably  it  has  been  a  real  hindrance  to  progress. 


CHAPTER    VIII. 
THE  AUTHOR'S  APPLIANCES. 

IN  the  descriptions  of  these  appliances  which  have  appeared  in  the 
different  editions  of  this  work,  they  have  been  divided  into  sets  and 
designated  as  Nos.  i  and  2,  with  a  few  auxiliary  parts.  As  some 
of  the  parts  are  more  frequently  demanded  in  use  than  others,  the 
grouping  into  sets  has  been  discontinued  and  the  parts  will  hereafter 
be  designated  separately.  All  parts  of  a  kind  are  thoroughly  inter- 
changeable and  each  accurately  fits  the  part  to  which  it  belongs, 
but  as  they  only  fit  the  parts  for  which  they  are  intended,  and  as  they 
will  be  referred  to  often  in  the  pages  which  sEall  follow,  it  is  very 
important  that  the  student  memorize  their  sizes  and  shapes,  as  well 
as  the  letters  or  figures  by  which  they  are  designated. 

FIG.  47. 

H 


F  and  H,  Fig.  47,  are  coils  of  band  material  from  which  are  made 
plain  bands  to  be  placed  upon  the  teeth  to  be  moved,  to  serve  as 
mediums  of  attachment  for  the  regulating  appliances,  as  well  as 
forming  part  of  the  retaining  devices.  Each  coil  is  twenty-four 
inches  in  length  and  will  furnish  a  considerable  number  of  bands. 

F  is  narrower  and  thinner  than  H,  and  is  usually  used  for  banding 
the  lower  incisors  and  upper  laterals. 

H  is  for  forming  bands  for  the  cuspids  and  upper  central  incisors. 

7 


82 


MALOCCLUSION. 


Fig.  48  represents  six  adjustable  clamp  bands  for  encircling  the 
molars  and  bicuspids,  usually  used  for  attaching  the  appliances  to 
the  teeth  used  as  anchorage. 


FIG 


No.  i. 


X  Band. 


DBand. 


Nos.  I  and  2  are  plain.  Nos.  3  and  4  are  provided  with  strong 
headed  pins,  soldered  to  their  sides.  These  two  bands  were  espe- 
cially designed  for  the  treatment  of  fractures  of  the  maxillae,  and 
their  use,  therefore,  is  fully  described  in  that  portion  of  this  work 
devoted  to  the  treatment  of  such  fractures.  They  are  also  useful 
in  the  attachment  of  ligatures  in  the  regulation  of  teeth,  described 
later. 

X  and  D  are  provided  with  tubes  of  smooth  bore,  soldered  to  their 
sides,  into  which  the  ends  of  the  arches,  described  later,  accurately 
fit. 

FIG.  49. 


The  retaining  wire  G,  Fig.  49,  consists  of  a  section  of  very  soft, 
smooth  wire.     Its  uses  are  numerous,  chief  of  which  are  the  rein- 


THE  AUTHOR'S  APPLIANCES.  83 

forcing  of  anchorage,  the  formation  of  spurs  upon  bands  for  the  at- 
tachment of  ligatures,  the  retention  of  teeth,  and  the  moving  of 
teeth.  The  latter  purpose  is  effected  by  securing  one  end  of  a  short 
section  against  the  tooth  to  be  moved,  with  the  other  end  suitably 
anchored,  then  lengthening  the  wire  by  pinching  with  the  regulating 
pliers,  Fig.  90. 

This  wire  is  provided  with  ten  delicate  tubes  known  as  retaining 
tubes,  R,  Fig.  50,  which  slide  closely  on  its  surface.  These  tubes 
are  used  in  detachable  connections,  in  reinforcing  anchorage,  in  re- 
tention, etc. 

FIG.  50. 

*  7 

-i  * 

Fig.  51  represents  the  jack-screw,  E  and  J  (enlarged  to  better 
show  the  parts),  consisting  of  a  threaded  shaft  provided  with  a  nut 
and  incased  in  a  tube  of  smooth  bore  accurately  fitting  the  shaft. 
Two  lengths  of  these  tubes  are  provided  to  meet  varying  require- 
ments. If  the  base  of  the  screw  be  made  to  rest  against  a  suitable 
anchor  tooth  with  proper  attachments  and  the  flattened  end  made  to 
engage  with  suitable  attachments  on  a  tooth  to  be  moved,  by  turn- 
ing the  nut  the  appliance  will  be  lengthened  and  force  exerted  upon 
the  moving  tooth. 

FIG.  51. 


A  valuable  improvement  has  recently  been  added  to  this  useful 
device,  consisting  of  a  friction  sleeve  or  extension  flange  forming 
part  of  the  nut,  which  accurately  telescopes  the  end  of  the  sheath 
enlarged  for  its  accommodation,  as  shown  in  the  engraving.  It  is 
more  particularly  described  in  Chapter  XI,  in  connection  with  the 
expansion  arch. 

A  and  D  and  Y,  Fig.  52,  is  a  traction  screw.  It  consists  of  a 
shaft  A,  bent  sharply  at  right  angles  at  one  end  and  at  the  other 
threaded  and  provided  with  a  nut,  with  three  accurately  fitting  tubes 
of  smooth  bore, — one  long,  Y,  and  two  short,  D.  If  the  long  and 


84 


MALOCCLUSION. 


one  of  the  short  tubes  have  been  soldered  to  tooth  bands  upon  the 
anchor  and  moving  teeth  respectively,  and  the  angle  of  the  screw 
made  to  engage  the  tube  D,  as  in  Fig.  53,  by  tightening  the  nut,  a 
pulling  force  will  be  exerted  upon  the  moving  tooth.  If  the  nut 
be  placed  against  the  other  end  of  the  tube  and  tightened,  it  will 
push. 

This  device  is  indispensable,  although  its  use  is  chiefly  limited  to 
the  retraction  of  the  cuspid,  as  shown  in  Fig.  53.* 

FIG.  52. 


E.H.A 


FIG.  54. 


Fig.  54  shows  a  bundle ,oi  spring  levers  L,  in  four  different  sizes. 
These  levers  are  still  made  from  piano-wire,  on  account  of  its 
superior  elasticity ;  yet  because  of  its  tendency  to  rapid  corrosion, 
no  matter  how  heavily  plated,  and  the  consequent  discoloration  of 
the  teeth,  its  ordinary  use  is  objectionable.  This  has  led  to  the 
discovery  of  new  combinations  of  other  appliances,  described  later, 
which  have  obviated  the  necessity  for  its  use  to  a  large  extent,  yet 
not  wholly.  The  principal  use  of  the  levers  is  in  the  rotation  of 
teeth  in  their  sockets. 

*In  the  former  editions  of  this  work  a  traction  screw  similar  to  the  one 
here  shown,  but  smaller,  was  advocated.  As  new  combinations  of  other 
devices  hereafter  described  better  serve  the  purpose  for  which  the  smaller 
screw  was  designed,  the  author  has  dispensed  with  its  use  in  his  own 
practice,  and  has  therefore  thought  it  advisable  to  omit  it  from  these  pages. 


THE   AUTHOR  S    APPLIANCES.  85 

Fig.  55  illustrates  a  small  wrench  of  universal  application  to 
all  the  various  nuts  and  appliances ;  it  is  nickel-plated  and  finely 
finished. 

Fig.  56  represents  the  expansion  arch  E.  It  is  a  very  elastic 
round  bar  bent  to  conform  approximately  to  the  outside  of  an  ideal 
dental  arch.  The  sides  of  this  arch  are  threaded  and  provided  with 
friction  sleeve  nuts,  which,  with  the  threaded  portion  of  the  arch, 
accurately  fit  the  smooth-bore  tubes  of  the  X  or  D  bands.  It  has 
the  widest  range  of  uses  in  tooth  movement.  With  its  attachments 

FIG.  55. 


FIG.  56. 


it  is  ample  for  the  treatment  of  a  large  percentage  of  cases,  and 
in  combination  with  the  traction  screw,  to  be  described  later,  this 
percentage  is  considerably  increased.  Its  principal  use  is  for  the 
movement  of  teeth  singly  or  en  masse  in  any  or  all  of  the  various 
directions,  except  distally.  For  this  movement  it  is  unsuited  for 
important  reasons  given  later.  The  teeth  to  be  moved  are  attached 
to  it  by  means  of  ligatures. 


86 


MALOCCLUSION. 


The  arch  B,  Fig.  57,  is  a  smooth,  threadless  arch,  similar  in  form 
and  temper  to  E.     It  is  also  always  used  with  the  clamp  bands  D  or 


FIG.  57. 


X,  and  in  addition  the  traction  bar  and  head- 
gear with  heavy  elastic  bands,  described 
later  and  shown  in  Fig.  59.  This  combina- 
tion of  appliances  is  for  shortening  the  den- 
tal arch,  or  moving  distally  en  masse  pro- 
truding incisors  and  cuspids.  The  anterior 
part  of  the  arch  B  is  prevented  from  sliding 
up  or  down  upon  the  surfaces  of  the  incisors 
by  being  made  to  rest  in  notches  in  plain 
bands,  C  C,  made  from  F  or  H,  Fig.  47, 
cemented  upon  them. 

The  traction  bar  A,  Fig.  58,  is  provided 
with  a  standard  in  its  center,  having  a  socket 
for  the  reception  of  a  delicate  ball  on  the 
center  of  the  arch  B.  The  hooked  ends  of 
the  traction  bar  receive  two  heavy  elastic 
bands  on  each  side,  which  exert  force  from 
the  head-gear  upon  the  moving  teeth,  as 
shown  in  Fig.  59,  the  arch  being  carried 
distally,  its  ends  sliding  through  the  tubes 
of  the  bands  on  the  molars. 

As  the  traction  bar  and  head-gear  cannot  be  worn  constantly,  the 


THE  AUTHOR'S  APPLIANCES.  87 

teeth,  during  these  interruptions,  are  prevented  from  springing  back 
by  two  delicate  rubber  ligatures  tied  in  front  of  small,  immovable 

FIG.  59. 


collars  on  the  arch  by  means  of  floss  silk.     These  ligatures  are 
stretched  distally  and  slipped  over  the  ends  of  the  anchor  tubes,  as 


88 


MALOCCLUSION. 


in  Fig.  60,  thus  exerting-  a  constant,  gentle  force  which  automatic- 
ally retains  the  teeth  at  any  point  in  their  progress. 


FIG.  60. 


The  head-gear,  Fig.  61,  is  a  cap  of  silk  netting  covering  the 
back  of  the  head  and  laced  to  a  metal  rim  for  the  even  distribution 
of  force  exerted  by  the  heavy  elastic  bands.  This  cap  is  strong, 


E.H.A. 


artistically  made,  and  presents  a  very  neat  appearance.  It  is  non- 
collapsible,  and  may  be  easily  and  quickly  adjusted  to  fit  any  size 
of  head. 

The  chin  retractor,  Fig.  62,  is  used  only  in  connection  with  the 
head-gear.      It  is  made  of  aluminum,   is  light,  neat,  and  highly 


THE  AUTHOR'S  APPLIANCES.  89 

polished.  It  will  fit  all  cases,  it  being  only  necessary  that  the  fit  be 
approximately  accurate.  A  layer  of  absorbent  cotton  should  always 
be  placed  between  the  metal  and  the  chin. 

As  auxiliaries  to  the  appliances  already  enumerated,  ligatures  and 
strips  of  rubber  are  used. 

FIG.  62. 


Ligatures. — Of  these  there  are  three  kinds.  First,  the  rubber, 
which  is  best  made  by  punching  a  hole  in  thick  rubber  dam  or  a  thin 
elastic  band  with  a  rubber-dam  punch,  then  trimming  the  outside 
down  to  the  desired  size.  Ligatures  made  in  this  way  are  much 
superior  to  those  cut  from  tubing,  as  any  desired  size  and  strength 
may  be  quickly  made  and  a  better  quality  of  rubber  is  insured. 
Their  use,  however,  in  this  system  is  greatly  limited. 

Second,  knitting  or  floss  silk.     The  latter  should  be  waxed. 

Third,  wire.  Each  possesses  advantages  in  certain  cases,  wire 
being  by  far  the  most  useful.  It  was  introduced  in  the  fourth 
edition  of  this  work,  for  use  in  connection  with  the  expansion  arch, 
and  has  proved  to  be  one  of  the  most  valuable  additions  made  to 
orthodontia  in  recent  years.  Its  advantages  and  uses  are  described 
in  Chapter  XI,  in  connection  with  the  arch. 

The  different  forms  of  wire  ligatures  are  shown  in  Fig.  63,  and 
should  be  carefully  studied. 


90  MALOCCLUSION. 

The  wedges  of  rubber  are  principally  used  for  exerting  pressure 
upon  some  tooth  of  overprominence  or  to  intensify  the  force  of  the 
lever  or  expansion  arch  in  rotating  teeth,  one  of  the  strips,  Fig.  64, 
of  suitable  thickness  being  stretched  nearly  to  its  limit  and  drawn 

FIG.  63. 


1/8  IN.  WIDE  3/16IN.    WIDE 

•  •••     mi 


between  tooth  and  appliance,  the  tension  then  released  and  super- 
fluous ends  cut  off,  as  in  Fig.  65.  The  rubber  conforms  so  perfectly 
to  the  shape  of  the  tooth  and  appliance  that  the  annoyance  of  slip- 
ping is  entirely  obviated  and  much  added  force  is  given  to  the  ap- 
pliances. 


THE   AUTHOR  S    APPLIANCES.  91 

It  will  be  seen  that  the  appliances,  independent  of  their  attach- 
ments, are  but  five  in  number  and  very  simple  of  form,  consisting 
of  the  jack-screw  for  pushing,  the  traction  screw  for  pulling,  and 
the  lever  for  rotating,  the  arch  E  for  enlarging  the  dental  arch  in 
any  or  all  directions,  and  the  arch  B  for  shortening  the  dental  arch. 

The  appliances  being  so  few  in  number,  it  has  been  doubted  by 
some  in  the  past  whether  they  were  sufficient  to  meet  all  require- 
ments in  the  correction  of  malocclusion.  They  are  now  so  widely 
used  and  their  efficiency  is  so  thoroughly  established  that  this 
question  need  not  here  be  discussed.  Not  only  are  they  adequate 
for  all  cases,  from  the  simplest  to  the  most  complex,  within  the 
range  of  treatability,  but  their  saving  in  time  and  expense  to  the 
dentist  and  in  discomfort  to  the  patient  are  qualities  widely  ap- 
preciated. Another  advantage  is  the  ready  convertibility  of  certain 
of  the  parts  into  simple,  delicate,  yet  very  efficient  devices  for  the 
retention  of  teeth. 

Constant  effort  toward  improvement  has  resulted  in  the  discovery 
of  new  methods  of  manufacture  whereby,  with  specially  constructed 
machinery,  the  production  of  more  uniform,  better  proportioned, 
stronger,  and  finer  tempered  appliances  has  been  secured,  as  well 
as  heavier  plating,  finer  finish,  and  greater  accuracy  as  to  fit  of  parts, 
insuring  in  their  uses,  singly  or  in  proper  combinations,  the  greatest 
strength,  firmness,  and  efficiency. 

All  the  parts  of  appliances  used  in  this  system,  with  the  exception 
of  the  levers  L,  the  retraction  cap  for  the  chin,  and  the  wire  liga- 
tures, are  made  of  a  very  fine  quality  of  German  silver,  the  adopted 
formula  for  which  has  been  determined  upon  after  much  careful 
experimenting.  It  is  much  superior  to  the  ordinary  German  silver 
of  commerce. 

Tools. — For  uniting  the  different  parts  of  the  appliances  to  form 
the  various  combinations,  and  for  placing  them  in  position  upon  the 
teeth,  only  a  few  tools  are  necessary,  but  it  is  important  that  they 
should  be  of  the  best  selection,  and  some  of  them  of  special  design. 

First,  a  pair  of  soldering  pliers.  Those  shown  in  Fig.  66  are 
most  suitable,  their  delicate  proportions  and  peculiar  form  making 
them  especially  suited  for  holding  bands  and  small  pieces. 

Second,  another  pair  of  pliers,  as  in  Fig.  67,  for  placing  pieces  of 
solder  in  position,  picking  up  small  pieces,  etc. 

Third,  band-forming  pliers.     Those  shown  in  Fig.  68  were  de- 


MALOCCLUSION. 


signed  especially,  and  are  indispensable  for  band-making.     They 
are  also  very  useful  for  most  other  purposes  for  which  ordinary 


FIG.  66.      FIG.  67. 


FIG.  68. 


FIG.  69. 


flat-beaked  pliers   are  used,   and   are  provided   with   grooves   for 
holding  the  small  square  nuts  and  round  wire. 


THE    AUTHORS    APPLIANCES.  93 

Fourth,  wire-cutters.     The  style  shown  in  Fig.  69  is  preferable. 
Fir,.  70. 


Fir..  71. 


94  MALOCCLUSION. 

Fifth,  the  regulating  pliers  shown  in  Fig.  70,  for  lengthening  or 
shortening  wire.     They  are  most  useful. 

FIG.  72.  FIG.  73. 


Sixth,  a  pair  of  scissors,  Fig.  71,  for  trimming  bands,  clipping 
ligatures,  etc. 


SOLDERING. 


95 


Seventh,  pliers  for  twisting  ligatures  and  for  general  uses,  as 
shown  in  Fig.  72. 

Eighth,  an  ordinary  hand  mallet  and  band  driver,  as  in  Figs. 
73  and  74. 

FIG.  74. 


FIG.  75. 


And  last,   and   very   important,   a   suitable  lamp   for   soldering, 
Fig-  75- 


CHAPTER    IX. 

SOLDERING. 

As  many  of  the  parts  of  these  appliances  are  very  delicate,  it  is 
important  that  a  fine,  sharp,  steady  flame  shall  be  used  in  effecting 
their  union  by  solder.  A  large  or  uneven  flame  would  injure  and 
might  ruin  them.  The  author  greatly  prefers  the  Herapath  blow- 
pipe, Fig.  75,  operated  with  the  ordinary  foot-bellows,  as  it  pro- 


g6  MALOCCLUSION. 

duces  the  proper  flame,  Fig.  76,  of  most  intense  heat,  yet  under 
the  most  perfect  control,  while  both  hands  of  the  operator  are  left 
free. 

FIG.  76. 


Fig.  77  shows  a  bracket  table  devised  by  the  author  as  a  con- 
venience in  this  work.  It  is  covered  by  a  glass  slab  and  holds 
the  blow-pipe,  connected  by  tubing  with  the  foot-bellows.  The 
drawers  are  receptacles  for  tools  and  appliances. 

Notwithstanding  many  ingenious  spring  clamps  and  other  de- 
vices have  been  invented  for  holding  such  small  work,  yet  the  plan 
introduced  by  the  author  in  the  second  edition  of  this  book  is  far 
preferable  in  most  cases.  It  consists  in  holding  the  pieces  with  the 
fingers  while  being  soldered.  The  metal  of  which  these  appli- 
ances are  made  is  most  favorable  for  soldering  in  this  way,  it 
being  so  poor  a  conductor  of  heat  that  all  such  attachments  as  E, 
F,  H,  I,  and  K,  Fig.  100,  can  be  so  held  without  any  perceptible 
communication  of  heat  to  the  fingers,  provided  the  flame  be  suit- 
able. 

Where  union  of  a  small  tube  with  a  band  is  desirable,  as  in 
Fig.  76,  the  tube  is  best  held  in  contact  with  the  band  and  flame 
by  means  of  some  delicate  instrument  which  will  absorb  but  little 
heat.  One  of  Gates's  nerve-drills,  with  the  point  broken  off,  is 
nearly  the  ideal.  Where  two  of  the  small  tubes  are  to  be  united,  as 
in  Fig.  78,  the  pliers  may  be  used  in  supporting  one  of  them. 

This  method  of  soldering  is  not  difficult,  most  students  learn- 
ing it  readily.  The  only  point  which  may  seem  at  all  difficult  to 
the  beginner  is  the  holding  of  the  pieces  in  fixed  position  just  at 
the  time  the  solder  is  congealing.  This  is  accomplished  by  touch- 


SOLDERING. 


97 


ing  one  or  more  of  the  fingers  of  one  hand  with  those  of  the  oppo- 
site hand,  as  in  Figs.  76  and  78,  to  steady  them,  at  the  same  time 
holding  the  pieces  gently,  not  rigidly,  just  as  a  good  penman  holds 
a  pen.  After  a  little  practice  any  of  the  various  soldered  attach- 
ments may  be  easily  and  quickly  made.  All  of  those  shown  in 


FIG.  77. 


Figs.  loo  and  101  are  made  in  this  way.  In  such  attachments  as 
E,  F,  H,  and  K,  Fig.  100,  the  pieces  of  solder  may  be  kept  from 
flying  off  by  being  gently  held  in  position  between  the  pieces  to 
be  united.  Where  the  ends  of  small  tubes  are  to  be  united,  as  in  C 
and  D,  Fig.  100,  it  is  best  to  fuse  the  solder  upon  the  band,  then  hold 
the  small  tubes  by  means  of  the  straight  pliers,  Fig.  67,  in  contact 
with  the  solder  and  again  apply  heat,  as  otherwise  the  solder  would 
usually  be  drawn  into  the  tube. 


98  MALOCCLUSIOX. 

The  solder  best  adapted  for  uniting  the  different  parts  of  these 
appliances  is  ordinary  jewelers'  silver  solder  (easy  flowing),  al- 
though any  of  the  various  carats  of  gold  solder  may  be  used,  with 
cream  of  borax  for  a  flux.  Never  use  more  solder  than  is  neces- 
sary, especially  in  all  small  attachments — just  enough  to  make  the 
union. 

Always  avoid  overheating — apply  just  sufficient  heat  at  the  right 
point  from  a  fine  sharp  flame  to  thoroughly  fuse  the  solder.  In 
every  instance  avoid  heating  the  screws  or  nuts.  This  is  to  be 
especially  observed  with  the  jack  and  traction  screws,  as  great  care 

FIG.  78. 


is  used  in  their  manufacture  to  preserve  their  stiffness  and  strength, 
and  this  fine  temper  would  be  ruined  by  heating.  The  arches  E  and 
B,  which  are  manufactured  in  such  a  way  as  to  give  them  the 
greatest  possible  spring,  second  only  to  steel,  might  also  be  easily 
ruined  by  heating. 

Soft-soldering. — It  is  often  necessary  to  attach  spurs  to  the  arches 
B,  which  are  manufactured  in  such  a  way  as  to  give  them  the 
ertion  of  force  in  the  desired  direction.  If  these  spurs  be  attached 
by  means  of  the  ordinary  soft  solder  used  by  jewelers  the  temper 
of  the  arches  will  not  be  injured,  provided  only  a  very  small  passive 
flame  be  used,  just  sufficient  to  melt  the  low-fusing  solder. 

The  best  plan  for  making  these  spurs  is  to  fuse  a  very  small 
piece  of  the  solder  upon  the  end  of  a  section  of  the  ligature  wire 
(first  having  dipped  the  end  of  the  wire  in  soldering  fluid),  then 
holding  the  solder  and  end  of  the  wire  in  contact  with  the  arch 


SOLDKRIXG.  99 

in  the  flame.  This  gives  a  fine,  conical  spur  with  brass  center, 
which,  is  very  strong,  yet  inconspicuous.  Fig.  79  shows  the  spur 
before  and  after  the  surplus  wire  has  been  cut  off.  Another  plan 
is  to  bend  the  wire  over  the  labial  surface  of  the  expansion  arch  in 
the  form  of  a  half  collar,  secure  it  with  solder,  and  trim  down  the 
ends.  This  is  stronger  than  the  other  spur,  but  is  more  conspicu- 
ous. 

FIG.  79. 


The  soldering  fluid  for  making  these  attachments  may  be  of  two 
kinds :  first,  that  known  as  jewelers'  soldering  fluid  (nitro-muriate 
of  zinc),  second,  the  ordinary  phosphoric  acid  used  in  the  oxy- 
phosphate  cements.  The  latter,  which  we  prefer,  is  cleaner  and 
does  not  discolor  the  gold-plating  of  the  arches.  With  this  the 
soldering  is  somewhat  more  difficult,  but  after  a  little  experience 
is  easily  accomplished.  It  being  highly  important  that  appliances 
worn  in  the  mouth  should  always  present  as  neat  an  appearance  as 
possible,  only  as  much  solder  should  be  used  in  attaching  these 
spurs  as  is  absolutely  necessary.  The  spur  should  be  no  higher 
than  the  diameter  of  the  ligature  it  is  intended  to  support,  as  it 
would  be  unsightly,  and  would  abrade  the  lips  or  interfere  with 
their  movements. 


IOO  MALOCCLUSION. 

All  these  points  should  be  carefully  considered.  See  further 
instructions  in  Chapter  XXI,  on  Technique. 

Plain  Bands. — As  the  plain  band  forms  such  an  important  part 
in  so  large  a  percentage  of  modern  regulating  appliances,  and 
especially  in  this  system,  it  is  important  that  proper  methods  be 
employed,  not  only  in  the  making  but  in  the  setting  of  the  same. 
So  erroneous  are  many  of  the  directions  given  by  authors  and  so- 
crude  are  some  of  the  different  methods  of  making  these  bands,  that 
it  may  not  be  amiss  to  here  point  them  out. 

First,  it  is  the  plan  of  some  to  adjust  the  appliance  to  the  plaster 
model,  forming  the  bands  over  the  plaster  teeth,  and  then 
to  transfer  it  to  the  mouth.  A  more  crude  or  inaccurate  method 
could  hardly  be  devised,  as  it  is  impossible  to  pinch  or  burnish 
band  material  about  a  plaster  tooth  so  that  its  final  fit  to  the  natural 
tooth  will  be  at  all  accurate,  and  it  must  soon  loosen  under  the 
necessary  strain  of  tooth  movement. 

Another  but  slightly  less  crude  method  is  to  cast  the  form  of 
the  tooth  in  metal,  around  which  the  band  is  hammered  and  molded 
to  the  desired  form. 

Another  method  is  to  make  a  band  in  a  similar  way  and  then  to- 
cover  it,  forming  an  entire  crown  for  the  tooth.  This  of  all 
methods  is  the  most  absurd,  for  unless  the  tooth  be  mutilated 
such  a  band  must  be  imperfect  of  fit,  bulky,  and  occupy  valuable 
space,  and  also  often  directly  interfere  with  occlusion,  while  the  firm- 
ness of  attachment  is  no  greater — probably  less  great — than  with 
a  plain  or  clamp  band  correctly  made  and  properly  set  with  suit- 
able cement. 

Still  another  method,  much  better,  but  never  admitting  of  any 
considerable  degree  of  accuracy,  is  to  burnish  a  short  piece  of 
band  material  about  the  tooth,  overlap  the  ends,  and  solder. 

One  author  directs  that  the  band  shall  be  made  larger  than  the 
tooth  in  order  to  provide  space  for  the  cement.  The  error  of  this 
is  obvious,  for,  notwithstanding  the  greatest  care  and  accuracy 
possible  in  the  fitting  of  the  band,  there  will  still  be  room  for  suffi- 
cient cement  if  it  be  properly  mixed.  The  chief  disadvantage  of  a- 
band  larger  than  the  tooth  is  that  its  attachment  will  be  far  less 
firm  than  if  the  fit  were  accurate,  and  it  will  almost  invariably  loosen 
under  the  strain  necessary  in  tooth-movement. 

The  last  method  to  be  here  considered  is  the  use  of  a  strip  of  metal 


SOLDERING.  IOI 

in  length  not  quite  sufficient  to  encircle  the  crown  and  having 
soldered  upon  its  outer  surface,  near  the  ends  and  at  right  angles 
to  them,  two  small  buttons,  around  which  ligature  wire  is  wound 
in  the  form  of  the  figure  8,  thus  completing  the  union  of  the 
ends  of  the  bands  by  tying.  This  form  of  band  possesses  no  ad- 
vantages over  the  brazed  band,  but  on  the  contrary  has  many 
disadvantages.  It  is  bulky  and  uncleanly  and  will  loosen  under  the 
.strain  of  tooth-movement  far  more  easily,  besides  being  more  ex- 
pensive and  requiring  more  time  in  tying  than  is  needed  in  brazing. 

We  have  already  stated  our  reasons  for  preferring  German 
silver  for  the  making  of  regulating  appliances,  and  especially  for 
the  making  of  bands,  in  Chapter  VII,  yet  this  metal  varies  greatly  in 
quality,  not  only  on  account  of  differences  in  the  formulae  from 
which  it  is  made,  but  also  on  account  of  the  manner  of  manipulation 
in  manufacture. 

It  is  important  that  it  shall  be  of  the  proper  fineness,  diameter, 
and  temper,  or  it  will  be  harsh  and  unyielding  and  difficult  or  im- 
possible of  proper  adaptation  to  the  form  of  the  tooth,  in  which 
case  it  will  loosen  more  readily  under  the  strain  of  tooth-move- 
ment, will  occupy  unnecessary  space  between  the  teeth,  and  pre- 
.sent  a  less  pleasing  appearance. 

To  simply  pinch  a  short  piece  of  band  material  about  the  tooth, 
as  has  been  recommended  by  some  authors,  is  to  make  a  loose 
fit  and  an  imperfect  band,  Fig.  81.  Pieces  of  generous  length 
should  be  used,  sufficient  to  firmly  grasp  with  thumb  and  fingers 
after  it  has  been  slipped  around  the  tooth  to  the  desired  point,  so 
that  considerable  force  may  be  exerted  by  the  hand  alone  in 
•drawing  the  loop  firmly  about  the  tooth  at  the  time  when  the  band 
is  pinched  by  the  band-forming  pliers,  Fig.  68. 

By  this  method  sufficient  pressure  is  brought  to  bear  to  make 
it  fit  with  the  greatest  accuracy  the  surface  of  the  tooth  around 
which  it  is  drawn,  and  if  the  surplus  ends  be  cut  off  so  they  will 
still  be  united,  as  in  Fig.  80,  there  will  be  very  little  waste  to 
the  strips  of  band  material  and  ample  length  for  a  firm  grasp  will 
always  be  insured.  By  exercising  the  proper  care  a  considerable 
number  of  bands  can  be  made  from  one  of  the  coils  of  band  material, 
either  F  or  H. 

No  one  should  expect  other  than  a  very  crude  band  if  rough  and 
loose-fitting  pliers  be  used  for  pinching,  for  the  junction  of  the 


IO2 


MALOCCLUSION. 


pinched  portion  will  then  be  rounded,  as  in  Fig.  81,  instead  of 
sharp  and  at  right  angles,  as  in  Fig.  82. 


FIG.  80. 


FIG.  82. 


Many  advantages  will  be  found  in  the  use  of  the  new  band-form- 
ing pliers,  Fig.  83,  which  so  perfectly  meet  the  requirements  and 
which  are  so  easy  of  access  to  all  surfaces  of  any  of  the  teeth,  so 
that  the  seam  can  be  as  readily  made  on  the  lingual  surface  as  on 
the  labial,  insuring  a  smooth,  unbroken  joint  when  soldered,  Fig.  80. 

In  soldering  a  band  either  gold  or  silver  solder  may  be  used. 
A  portion  about  one-eighth  of  an  inch  square  wet  with  borax 
cream  is  placed  between  the  angles  of  the  band  and  held  by  means 
of  the  new  band-soldering  pliers,  Fig.  84,  over  the  sharp  flame 
of  the  Herapath  blow-pipe.  With  these  pliers  uniform  pressure 

*Essig's  "American  Text-book  of  Prosthetic  Dentistry." 


SOLDERING. 


103 


is  exerted  at  the  exact  points  necessary  to  insure  the  seam  being 
even  and  perfect,  while  the  minimum  amount  of  heat  only  is  ab- 
sorbed by  the  pliers,  consequently  no  change  of  form  or  injury  to 
them  is  possible.  A  further  advantage  of  their  use  is  that  their 
points  rest  in  contact  with  the  band  material  in  such  position  as 
to  be  shielded  from  the  solder,  so  that  none  will  be  fused  upon  the 
points,  thus  avoiding  an  annoyance  of  no  small  moment  that  ;s 


FIG.  84. 


often  encountered  in  the  use  of  ordinary  pliers,  their  contact  with 
the  solder  being  almost  a  necessity.  They  will  be  found  to  be  a 
great  improvement  over  those  heretofore  used  for  the  purpose. 

To  insure  the  flowing  of  the  solder  in  the  seam  only,  plenty  of 
borax  should  be  placed  there  but  none  on  the  inner  surface  of  the 
band,  as  otherwise  the  solder  would  be  drawn  from  the  seam  and 
there  would  be  faulty  union  or  a  thickening  of  the  band,  either  of 
which  would  render  it  entirely  useless.  When  soldered  the  band 


IO4 


MALOCCLUSION. 


should  present  a  continuous,  even  inner  surface.  Any  other  union 
is  imperfect  and  should  not  be  used.  The  band  being  properly 
fitted,  it  is  ready  for  any  attachments  which  may  be  required. 

Let  us  again  insist  upon  the  importance  of  a  very  hot,  fine,  sharp- 
pointed  flame  in  the  making  of  all  these  attachments,  as  neatness 
in  such  delicate  soldering  is  impossible  with  a  coarse  flame.  With 
the  proper  flame  such  attachments  may  be  made  almost  instantly 

Fir,  85. 


FIG.  86. 


without  injury  to  the  delicate  pieces  of  the  appliances,  and  before 
the  heat  can  be  transmitted  to  those  portions  held  by  the  fingers. 
The  flame  from  the  ordinary  blow-pipe  is  wholly  unsuited. 

The  principal  soldered  attachments  to  the  plain  bands  are  tubes 
R,  spurs  and  staples.  The  two  latter  are  made  from  the  wire  G, 
as  shown  in  D,  E,  G,  and  H,  Fig.  85,  and  B,  Fig.  63. 

The  attachment  of  a  spur  is  best  accomplished  by  heating  the 
smoothened  end  of  the  wire  G,  touching  it  to  a  large  piece  of  borax, 
holding  it  in  contact  with  a  small  piece  of  solder  in  the  flame  until 
it  is  partially  fused,  then  bringing  it  in  contact  with  the  band  at 
the  desired  point  and  again  holding  in  the  flame.  After  it  is  fused. 


SOLDERING.  1 05 

Fig.  86,  it  is  clipped  off  with  the  wire-cutters  to  the  desired  length, 
which  should  never  be  greater  than  one-thirty-second  of  an  inch, 
and  the  roughened  end  made  smooth  with  a  file.  But  little  solder 
should  be  used,  as  a  large  amount  would  form  an  incline,  which 
would  not  so  well  hold  the  ligature. 

If  a  staple  is  to  be  made  the  end  of  the  wire  is  bent  into  the 
form  of  the  letter  U,  the  solder  is  flowed  upon  the  surface  of  the 
band  first,  then  the  convex  portion  of  the  staple  is  held  in  contact 
and  the  solder  re-fused,  after  which  the  ends  are  clipped  to  about 
one-sixteenth  of  an  inch  in  length  and  smoothed  with  a  file,  as  in 
E  and  H,  Fig.  85.  The  jaws  of  the  staple  should  be  close  enough 
together  to  prevent  much  play  of  the  piece  it  is  to  engage. 

When  an  oval  loop,  as  in  D  and  G,  Fig.  85,  is  to  be  attached, 
the  solder  should  be  flowed  first  upon  the  band  and  only  in  suffi- 
cient quantity  to  secure  the  loop  at  the  given  point.  A  larger 
amount  is  unnecessary,  and  might  be  drawn  into  the  cavity  of  the 
loop. 

The  attachment  of  one  of  the  tubes  R,  as  in  C  and  D,  Fig.  100, 
and  B,  Fig.  101,  should  be  made  by  also  first  flowing  a  minute 
portion  of  solder  upon  the  band,  then  holding  the  end  of  the  tube 
in  contact  with  it  and  re-applying  heat.  If  the  side  of  the  tube 
is  to  be  soldered  to  the  band,  as  in  Fig.  167,  it  should  be  done  in 
the  same  manner  as  shown  in  Fig.  76. 

It  is  desirable  that  all  attachments,  both  for  moving  the  tooth 
and  in  anticipation  of  retention,  shall,  if  possible,  be  made  before 
first  setting  the  band,  in  order  that  the  pain  and  trouble  of  removal 
and  substitution  of  a  new  band,  after  the  teeth  have  become  .tender, 
may  be  avoided. 

The  untrimmed  ends  of  the  band  serve  the  useful  purpose  of  a 
handle  for  holding  it  in  the  flame  and  in  contact  with  the  piece  to 
be  attached,  as  in  G  and  H,  Fig.  85,  and  Fig.  86.  After  the  attach- 
ments have  been  made  the  ends  of  the  bands  are  trimmed  off, 
leaving  them  long  or  short,  as  desired.  If  a  niche  is  to  be  formed, 
as  in  C  C,  Fig.  57,  or  A,  Fig.  85,  the  ends  are  left  about  one-six- 
teenth of  an  inch  long,  but  if  they  are  not  to  serve  as  a  means  of 
attachment  they  may  be  trimmed  still  shorter,  though  it  is  never 
desirable  to  trim  them  even  with  the  surface  of  the  band.  The 
sharp  corners  should  be  rounded  by  means  of  a  fine  flat  file.  The 
united  ends  may  be  further  strengthened  by  an  extra  piece  of  the 


106  MALOCCLUSION. 

band  material  held  between  the  jaws  at  the  junction  when  soldering; 
this,  however,  is  rarely  necessary. 

When  the  band  is  ready  to  be  cemented  upon  the  tooth  it  is 
first  boiled  in  a  few  drops  of  dilute  sulfuric  acid,  in  a  small  test- 
tube  or  other  suitable  vessel,  then  washed  and  dried,  or  dipped  in 
phosphoric  acid  and  held  in  contact  with  the  flame  until  the  fluid 
is  partially  evaporated -by  boiling,  then  washed.  This  is  the  author's 
favorite  method  of  deoxidizing  most  small  pieces. 

The  tooth  is  cleansed  with  pumice,  followed  by  alcohol  or  ether, 
then  dried  with  the  chip-blower  and  protected  from  moisture  by  a 
small  roll  of  cotton  or  bibulous  paper.  The  band  is  filled  with 
oxyphosphate  of  zinc  of  creamy  consistence,  then  carried  on  the 
end  of  the  finger  to  the  tooth,  upon  which  cement  and  band  are 
pressed.  With  the  fingers  alone  the  band  is  carefully  worked 
nearly  to  its  desired  position  and  then  driven  down  by  a  few7  gentle 
taps  from  the  mallet  and  band-driver  (Figs.  73  and  74).  The 
burnisher  is  now  quickly  applied  to  the  edges  of  the  band  only,  and 
the  surplus  cement  wiped  off.  When  the  cement  has  thoroughly 
hardened  the  band  should  be  carefully  polished  and  burnished,  as 
it  is  well  known  that  discoloration  is  far  less  liable  with  a  smooth, 
polished  surface  than  with  a  rough  one. 

The  polishing  is  best  effected  by  means  of  the  ordinary  leather 
polishing  wheels,  delicate  of  size  and  sharp  of  edge,  with  pumice. 
A  band  so  made  and  set  will  fit  with  the  most  glove-like  accuracy, 
will  present  a  very  neat  appearance,  and  will  not  loosen  under 
strain.  It  should  be  remembered,  however,  that  only  a  perfectly 
fitting  band  can  be  firmly  attached.  If  it  is  defective  in  any  par- 
ticular, as  too  large,  weakened  by  crimping,  or  slightly  torn  when 
driven  into  position,  it  should  be  immediately  condemned  and  a 
more  perfect  one  substituted,  for  sooner  or  later  it  will  surely  fail 
and  cause  annoyance. 

\Yhen  it  is  desired  to  loosen  the  band,  never  attempt  to  do  so 
with  forceps  or  pliers.  That  is  a  clumsy  way  and  involves  too 
great  risk.  The  band  should  be  cut  with  the  delicate  point  of  a 
sharp  knife,  gently  worked  between  enamel  and  band. 

In  banding  a  tooth  where  there  is  much  crowding  of  the  teeth, 
sufficient  space  may  usually  be  made  between  the  tooth  to  be 
banded  and  those  adjoining  by  stretching  and  working  a  strip  of 
band  material  between  the  teeth  on  one  side  and  allowing  it  to  re- 


SOLDERING.  lOJ 

main  in  position  a  few  moments,  after  which  the  opposite  side  of 
the  same  loop  may  in  like  manner  be  worked  between  the  teeth 
on  the  opposite  side.  The  loop  is  then  drawn  tightly  about  the 
tooth  with  the  fingers  only,  and  if  lateral  pressure  be  considerable 
it  is  best  to  trim  off  the  surplus  ends  of  band  material  and  allow 
this  wedging  band  to  remain  in  position  over  night  before  band- 
ing in  the  usual  way.  Usually,  however,  by  exercising  a  little  care 
and  patience,  the  banding  may  be  done  at  one  sitting  if,  upon 
pinching  and  removal  of  the  band,  pieces  of  band  material  be  im- 
mediately worked  into  the  spaces  already  gained  and  allowed  to 
remain  while  the  band  and  its  attachments  are  being  completed. 

The  cuspid  is  the  most  difficult  of  any  of  the  teeth  to  band,  but 
by  forming  the  seam  on  the  lingual  incline  and  firmly  burnishing 
the  outer  surface  while  it  is  being  pinched,  an  accurate  fit  can 
in  most  instances  be  made.  Another  plan  is  to  pinch  a  fold  in  the 
band  on  the  lingual  incline,  while  it  is  being  firmly  pinched  and 
drawn  with  the  fingers  on  the  opposite  side.  The  band  is  then 
removed  and  a  little  solder  flowed  into  the  fold.  It  is  then  re- 
placed and  the  seam  made  upon  the  labial  surface  by  pinching, 
burnishing,  etc.,  in  the  usual  way. 

Adjustment  of  the  Anchor  Clamp  Bands. — The  clamp  bands  were 
designed  to  be  used  upon  the  molars  and  bicuspids,  as  the  shapes 
of  these  teeth  and  their  positions  in  the  mouth  make  it  substantially 
impossible  to  fit  plain  bands  to  them  so  that  they  will  not  soon  loosen 
under  the  necessary  strain  of  tooth-movement.  The  clamp  bands 
are  easily  and  quickly  adjusted  upon  these  teeth,  and  may  be  readily 
removed  and  replaced  without  injury,  when  necessary. 

In  adjusting  a  clamp  band  the  nut  should  first  be  loosened  suf- 
ficiently to  allow  ample  size  for  the  crown  over  which  it  is  to  slip. 
The  band  should  then  be  shaped  between  the  flat  beaks  of  the  band- 
forming  pliers  until  it  conforms  approximately  to  the  shape  of  the 
crown  of  the  tooth,  the  shaft  of  the  screw  being  also  bent  if  neces- 
sary. It  should  then  be  carefully  worked  over  the  crown  with 
the  fingers  and  made  to  slide  between  gum  and  enamel  to  the 
desired  point.  It  should  then  be  alternately  clamped  and  bur- 
nished until  it  be  made  to  conform  accurately  to  the  shape  of  the 
crown. 

One  of  the  greatest  blunders  made  in  adjusting  these  bands  is 
to  trim  or  file  the  band  on  its  edge  in  order  to  prevent  supposed 


IO8  MALOCCLUSION. 

interference  with  the  gums.  Such  procedure  only  ruins  the  band. 
Besides,  it  is  essential  that  this  portion  of  the  band  shall  pass  be- 
yond the  swell  of  the  crown  and  be  clamped  and  burnished  to  the 
neck  of  the  tooth  to  prevent  its  slipping  off. 

Another  blunder  frequently  made  is  to  begin  the  clamping  or 
burnishing  before  it  is  well  over  the  crown.  In  this  case  part  of 
the  band  must  bear  the  entire  strain  and  will  be  stretched  or  torn. 

It  is  a  mistake  to  allow  the  screw  to  stand  out  at  too  great  an 
angle.  The  band  should  be  turned  before  clamping  until  the 
screw  be  in  close  contact  with  the  adjoining  tooth.  It  cannot  then 
interfere  much  with  the  movements  of  the  tongue  or  lips. 

The  bands  are  made  to  endure  the  greatest  possible  strain  con- 
sistent with  their  nearly  ideal  proportions.  They  will  therefore 
bear  considerable  tightening  of  the  nut,  yet  if  this  be  carried  too 
far  they  may  be  easily  broken.  Judgment,  not  mere  brute  force, 
is  required  in  their  adjustment.  It  is  usually  best  not  to  clamp 
the  band  too  tightly  at  first,  but  to  occasionally  inspect  and  grad- 
ually clamp  to  the  desired  tension.  The  clamping  of  the  bands 
is  ample  to  so  secure  them  in  position  that  cement  is  unnecessary 
except  in  effecting  stationary  anchorage,  as  in  the  use  of  the  trac- 
tion screw,  as  shown  in  Fig.  89.  If  the  bands  are  to  be  worn  for 
three  or  four  months  it  would  be  desirable  to  use  cement,  but 
only  as  a  means  of  preventing  the  possible  disintegration  of  the 
enamel  which  they  cover. 

FIG.  87. 


Fig.  87  shows  a  D  band  which  has  been  properly  adjusted  to 
the  crown  of  a  molar.  It  will  be  noted  that  it  accurately  conforms 
to  the  swell  of  the  crown.  A  small  portion  of  the  upper  edge  has 
been  burnished  over  the  distal  marginal  ridge,  to  prevent  the  possi- 
bility of  the  working  of  the  band  too  far  over  the  crown. 


ANCHORAGE.  ICX} 

In  order  to  gain  sufficient  space  between  crowded  teeth  for  the 
reception  of  the  bands,  the  directions  for  placing  the  plain  band 
in  similar  cases  should  be  followed. 

The  points  for  any  attachments  which  are  to  be  made  should  be 
indicated  by  a  small  mark  after  the  band  has  been  made  to  conform 
accurately  to  its  desired  position,  and  before  removing  it  from  the 
tooth. 


CHAPTER    X. 

ANCHORAGE. 

Principles  of  Anchorage. — In  the  application  of  force  for  the 
movement  of  teeth,  the  crowns  are  the  only  portions  available  for 
effecting  the  necessary  attachments.  Force  is  usually  exerted  at 
right  angles,  or  nearly  so,  to  the  long  axes  of  their  roots,  and  their 
changes  of  position  may  be  said  to  be  partial  or  complete. 

In  the  first  instance  the  change  is  principally  in  the  crown  end 
of  the  tooth,  it  being  tipped  into  position,  thereby  changing  its  angle 
of  inclination,  with  little  or  possibly  no  apical  displacement. 

In  the  second  case  the  tooth  is  moved  bodily,  its  coronal  and 
apical  displacement  being  more  or  less  equal,  and  in  the  same  di- 
rection. 

Whether  the  movement  shall  be  partial  or  complete  depends  upon 
the  manner  of  attachment,  which  determines  the  distribution  of  the 
applied  force.  In  the  first  instance  the  attachment  must  be  in  the 
nature  of  a  hinge  or  pivot,  so  as  to  admit  of  tipping,  as  would  follow 
the  use  of  a  ligature  made  to  exert  force  substantially  at  right  angles 
to  the  long  axis,  or  the  jack-screw  attached  by  means  of  a  pit  in  the 
enamel  of  the  crown,  A,  Fig.  100,  or  by  a  notched  band  cemented  on- 
the  crown,  Fig.  88,  or  from  the  traction  screw  in  pulling,  as  in  Fig. 
89. 

To  effect  the  second  form  of  movement  necessitates  that  the  at- 
tachment to  the  crown  shall  be  rigid,  as  well  as  the  appliance,  so 
that  tipping  will  be  impossible,  the  force  being  then  distributed 
equally  to  the  root.  Prof.  Calvin  S.  Case,  of  Chicago,  invented  the 
first  appliance  to  successfully  accomplish  this  movement,  exercis- 
ing in  its  construction  much  ingenuity  and  skill.  His  high  standing 


no 


MALOCCLUSION. 


in  the  profession  entitles  his  claims  to  respectful  consideration, 
yet  in  the  opinion  of  the  author  the  movement  is  of  uncertain  utility 
in  ordinary  practice.  It  necessitates  the  use  of  a  complex  appliance, 
obtrusive  in  appearance,  inconvenient  to  the  patient,  and  trouble- 
some to  the  operator.  The  author  believes  it  is  wholly  unnecessary, 
for  reasons  which  he  gives  in  the  chapter  on  Changes  Subsequent  to 
Tooth -Movement. 

The  movement  of  the  malposed  tooth  depends  upon  two  im- 
portant things:  first,  that  the  force  exerted  shall  be  sufficient  to 
effect  the  movement,  and  second,  that  the  anchorage  shall  be  suf- 
ficient to  resist  this  force. 


FIG. 


No.S 


Details  of  Anchorage.  —As  has  before  been  stated,  there  are  but 
seven  distinct  malpositions  which  teeth  can  occupy.  In  accordance 
with  laws  of  physics,  their  movement  into  harmony  with  the  line  of 
occlusion  can  only  be  accomplished  by  the  application  of  force  from 
a  fixed  base  of  anchorage  in  one  of  three  ways,  pulling,  pushing,  or 
twisting.  As  "for  every  action  there  is  an  equal  and  opposite  re- 
action," it  must  follow  that  the  same  amount  of  force  will  be  exerted 
upon  the  anchorage  as  upon  the  tooth  to  be  moved,  and  if  the 
anchorage  offer  no  greater  resistance  than  that  offered  by  the  tooth 
to  be  moved,  equal  displacement  of  both  must  follow. 

For  moving  teeth  we  have  two  principal  sources  of  anchorage, — 
first,  that  which  may  be  derived  from  the  teeth  themselves ;  second, 
that  gained  from  suitable  attachments  to  the  top  and  back  of  the 
head. 

An  accurate  knowledge  of  the  forms  and  surfaces  of  the  teeth  and 
their  occlusion,  the  surfaces,  lengths,  and  inclinations  of  their  roots, 


ANCHORAGE.  1 1 1 

and  the  structure,  density,  and  distribution  of  the  alveolar  process 
and  peridental  membrane,  is  essential  to  an  intelligent  comprehen- 
sion of  its  requirements  and  possibilities.  The  resistance  offered  by 
different  teeth  varies  greatly  according  to  their  position,  size,  length, 
and  number  of  roots,  the  direction  from  which  force  is  exerted,  and 
also,  as  we  have  said,  in  the  manner  of  mechanical  attachment. 

Of  the  many  improvements  in  the  methods  of  tooth  regulation 
perhaps  none  have  been  greater  than  the  modern  devices  for  secur- 
ing anchorage.  The  former  bulky  and  insecure  devices  for  this 
purpose,  in  the  form  of  vulcanite  or  metal  plates  or  cribs,  have 
practically  become  obsolete  since  the  introduction  of  the  plain  and 
clamp  bands  for  the  teeth,  which  make  possible  much  greater  control 
of  the  anchorage,  as  well  as  firmness  and  stability. 

The  force  should  be  as  direct  and  positive  as  may  be  possible 
with  the  conditions  at  our  disposal.  The  ideal  anchorage  would  of 
course  be  that  from  an  immovable  base.  This,  however,  is  probably 
never  fully  possible  in  the  mouth,  owing  to  the  slight  spring  of  the 
alveolus  and  cushion-like  function  of  the  peridental  membrane. 
Some  displacement  of  anchor  teeth  is  admissible,  provided  they  be 
kept  within  the  limits  of  final  restoration  by  means  of  the  inclined 
planes  of  the  occluding  teeth ;  but  if  greater  displacement  than  this 
occur,  malocclusion  of  the  anchor  teeth,  most  difficult  or  even  im- 
possible to  overcome,  may  be  established.  Hence  they  should  be 
closely  watched,  and  careful  measurements  and  comparisons  with 
the  original  models  be  frequently  made.  Any  movement  perceived 
should  be  promptly  combated.  The  embarrassment  following  any 
considerable  displacement  of  the  anchor  teeth  is  so  serious  that 
ample  anchorage  should  always  be  secured  in  the  beginning. 

The  anchorage  available  to  us  may  be  said  to  be  of  five  kinds. 
They  are  more  or  less  intimately  associated  and  are  used  in  combi- 
nations or  separately,  according  to  the  exigencies  of  requirement. 
We  will  designate  them  as  Simple,  Stationary,  Reciprocal,  Occipital, 
and  Occlusal. 

Simple  Anchorage  is  that  in  which  the  resistance  of  the  moving 
teeth  is  overcome  because  of  the  larger  size  or  more  favorable  lo- 
cation of  the  anchor  tooth,  as  in  Figs.  90  and  91,  the  form  of  at- 
tachment being  hinged  or  pivotal,  admitting  of  the  tipping  of  the 
anchor  tooth  in  its  socket.  This  form  of  anchorage,  though  often 
primarily  unreliable  in  itself,  may  be  reinforced  by  enlisting  the 


112 


MALOCCLUSION. 


resistance  of  other  teeth  in  the  same  arch,  near  or  remote  in  location. 
Fig.  92  shows  the  first  bicuspid  in  simple  anchorage,  reinforced  by 
all  the  incisors,  in  order  to  overcome  the  resistance  of  the  firmly 
implanted  cuspid  to  labial  movement. 


FIG.  90. 


FIG.  91. 


FIG.  92. 


Stationary  Anchorage  is  that  in  which  the  form  of  attachment 
is  essentially  rigid,  so  that  tipping  of  the  anchor  tooth  is  impossible, 
and  if  moved  at  all  it  must  be  dragged  bodily  through  the  alveolus 
in  an  upright  position.  Fig.  93  shows  an  illustration  of  stationary 
anchorage  to  a  molar  in  the  retraction  of  a  cuspid.  The  long 
sheath  of  the  screw  is  soldered  to  a  clamp  band  rigidly  cemented  and 
clamped  upon  the  molar,  while  the  angle  of  the  screw  engages  a  tube 
soldered  horizontally  to  a  plain  band  on  the  cuspid.  The  attach- 


ANCHORAGE.  113 

ment  to  the  cuspid  is  hinged  and  designed  for  tipping,  while  that 
to  the  molar  is  rigid,  to  prevent  tipping.  If  displacement  of  the 
molar  should  occur,  it  would  be  equal  its  entire  length. 

It  will  be  seen  that  the  anchorage  is  thus  enormously  increased 
over  the  simple  form.  So  efficient  is  it  that  the  retraction  of  a 
cuspid  has  been  accomplished  by  anchorage  to  a  bicuspid  alone,  with 
but  little  displacement  of  the  latter,  while  by  ordinary  anchorage 
all  three  molars  and  one  bicuspid  have  been  known  to  be  tipped  for- 
ward in  the  effort  at  retraction  of  the  cuspid  by  means  of  a  '"long 
clamp  band"  made  to  encircle  the  five  teeth. 

Skill  and  judgment  are  necessary  in  the  use  of  this  form  of 
anchorage,  for  its  success  depends, — first,  on  the  absolute  rigidity 
of  the  attachment  and  appliance,  and  second,  upon  care  that  the 

FIG.  93. 


force  exerted  be  not  at  any  time  so  great  as  to  strain  or  injure  it. 
This  is  of  vital  importance,  for  any  loosening  or  straining  of  it 
would  change  it  to  ordinary  anchorage.  (See  directions  for  adjust- 
ing clamp  bands  for  stationary  anchorage,  Chapter  IX.) 

This  valuable  form  of  anchorage  is  somewhat  limited  in  its  range 
of  usefulness  because  complete  rigidity  of  both  appliance  and  at- 
tachment is  not  always  possible.  We  shall,  however,  employ  it 
many  times  in  the  pages  that  are  to  follow.  It  was  introduced  by 
the  author  in  the  first  edition  of  this  book*  (see  also  Items  of  In- 
terest, December,  1887). 

Reciprocal  Anchorage  is  the  pitting  of  one  malposed  tooth  against 
another,  the  tendency  of  the  force,  correctly  applied,  being  to  move 
both  into  the  line  of  occlusion,  as  in  Fig.  94,  where  double  rotation 
of  the  centrals  is  being  accomplished  by  one  appliance  and  widening 

*Stationary  anchorage  was  first  employed  by  Dr.  Barrett,  by  means  of  a 
vulcanite  plate  entirely  covering  the  molars;  but  this,  of  course,  did  not 
admit  of  strict  rigidity  of  attachment. 

9 


114  MALOCCLUSION. 

of  the  arch  by  another,  the  rubber  ligatures  connecting  the  two 
being  used  merely  as  a  convenience,  to  expedite  the  movement  of  the 
centrals,  though  not  necessary  to  it. 

FIG.  94. 


FIG.  95. 


FIG.  96. 


Reciprocal  force  in  anchorage  admits  of  the  widest  range  of  ap- 
plication and  is  of  the  greatest  value.  Each  case  should  be  care- 
fully studied  with  a  view  to  its  use  whenever  possible,  either  in  its 
simplest  forms,  as  in  Figs.  95  and  96,  or  when  a  greater  number  of 
teeth  are  to  be  moved,  as  in  widening  the  arch,  as  in  Fig.  94,  or  in 
combination  with  other  forms  of  anchorage.  It  will  be  found  ap- 


ANCHORAGE.  115 

plicable  to  a  very  large  percentage  of  cases,  and  is  an  important 
principle  in  many  of  the  combinations  of  appliances  in  this  system. 

FIG.  97- 


Occipital  Anchorage  is  that  in  which  the  resistance  is  borne  by  the 
top  and  back  of  the  head  and  transmitted  by  means  of  the  head-gear 
and  heavy  elastics  to  attachments  upon  the  teeth,  as  in  Fig.  97. 


Il6  MALOCCLUSION. 

This  very  useful  and  well-known  form  of  anchorage  is  principally 
applicable  in  the  treatment  of  cases  belonging  to  Division  I  and  its 
subdivision,  Class  II,  and  to  Class  III. 

Occlusal  Anchorage  is  so  designated  by  the  author  because  the 
principle  involved  would  seem  to  require  distinction.  The  tooth- 
anchorages  already  described  depend  primarily  upon  the  lateral 
resistance  of  the  alveolus  to  the  roots  of  the  teeth.  In  the  present 
form  of  anchorage,  while  the  alveolus  affords  more  or  less  lateral 
resistance,  the  anchorage  is  principally  due  to  the  direct  or  indirect 
resistance  of  the  opposing  teeth  through  the  occlusal  planes,  as  in 
Figs.  98*  and  99,  where  impacted  cuspids  were  drawn  into  the  line 


FIG.  98. 


of  occlusion  by  means  of  rubber  ligatures  attached  to  the  opposite 
jaw.  This  form  of  anchorage  is  direct  and  powerful,  and  may 
often  be  employed  to  much  advantage.  Dr.  Baker's  modification 
of  this  form  of  anchorage,  shown  in  Fig.  255,  is  of  such  great  value 
that  it  is  the  author's  opinion  that  it  may  be  classed  among  the 
marked  steps  in  the  progress  of  tooth  regulation.  It  will  be  dis- 
cussed more  fully  hereafter. 


CHAPTER    XI. 

COMBINATIONS    OF   APPLIANCES. 

THE  hundreds  of  appliances  that  have  been  used  in  different 
hands  in  the  various  periods  of  dental  history  might  be  classified 
into  a  very  few  groups,  each  group  representing  merely  variations 
of  a  single  mechanical  principle.  Therefore  the  very  common  prac- 
tice of  advocating  indiscriminately  every  appliance  that  has  ever 
^Dental  Cosmos,  1891,  page  743. 


COMBINATIONS    OF    APPLIANCES.  1 17 

been  made  to  serve  a  purpose  is,  we  believe,  not  only  unnecessary, 
but  misleading  and  fruitful  of  much  harm. 

The  author  early  became  convinced  that  a  very  few  appliances, 
in  harmony  with  the  simple  laws  of  mechanics,  of  suitable  propor- 
tions and  interchangeable  parts,  would,  in  combination,  meet  all  re- 
quirements. It  has  been  his  constant  aim  to  simplify  and  minimize 
the  number  to  the  limit  consistent  with  the  necessities  of  practice. 
While  the  variety  of  combinations  possible  in  the  assembling  of  the 
several  parts  comprised  in  the  system  of  appliances  devised  by  the 
author  and  bearing  his  name  is  substantially  limitless,  yet  a  very 
few  of  these  possible  combinations  are  in  reality  sufficient  for  all 
purposes  of  orthodontal  practice.  Several  writers,  in  commending, 
from  time  to  time  mechanisms  constructed  by  practitioners  along 
lines  of  these  models,  have,  perhaps  unwittingly,  introduced  many 
unnecessary  combinations,  which  must  be  misleading  to  the  student 
or  inexperienced  practitioner. 

Thorough  familarity  with,  and  experience  in  the  use  of,  a  few 
appliances  of  desirable  form  will  reveal  possibilities  of  accomplish- 
ment which  would  never  follow  in  the  case  of  a  large  variety  each 
of  which  might  only  occasionally  be  used.  The  best  success  can 
be  achieved  only  by  persistent  concentration  of  mental  effort,  and 
success  will  be  modified  as  the  attention  shall  be  divided,  however 
great  the  earnestness  of  application. 

We  cannot  too  strongly  urge  the  minimizing  of  the  number  of 
appliances  to  the  absolute  requirements  of  use. 

Those  appliances  which  the  author  has  found  from  much  ex- 
perience to  be  the  most  useful  will  be  chiefly  specified  in  the  de- 
scriptions of  treatment  in  the  following  pages,  but  that  there  may  be 
ample  range  of  choice  a  number  of  others  will  also  be  mentioned  as 
being  possibly  desirable  in  certain  cases. 

Let  it  be  remembered  that  the  functions  of  regulating  appliances 
consist  in  the  movement  of  teeth  from  their  seven  malpositions 
into  harmony  with  the  line  of  occlusion  by  the  exertion  of  force  in 
pulling,  pushing,  and  twisting,  singly  or  in  combination. 

The  varied  requirements  in  the  establishing  of  occlusion  and  in 
harmonizing  the  sizes  of  the  arches  necessitate  that  the  appliances 
shall  not  only  move  teeth  singly  in  these  several  directions,  but  that 
they  shall,  on  occasion,  move  them  collectively  and  often  in  various 
directions  simultaneously.  For  example,  it  may  be  required  to 


n8 


MALOCCLUSION. 


move  buccally  one  or  both  of  the  lateral  halves  of  one  or  both  arches, 
or  to  lengthen  or  shorten  one  or  both  arches  in  front,  or  to  lengthen 
or  shorten  one  or  both  of  the  lateral  halves  of  one  or  both  arches, 
and  in  rare  instances  to  move  lingually  one  or  both  of  the  lateral 
halves  of  one  or  both  arches. 


A 


FIG.  ico. 
C  D 


Jack-Screw. — In  employing  the  jack-screw  for  exerting  force 
upon  teeth  to  be  moved  the  base  of  the  sheath  may  be  secured  in 
various  ways,  as  shown  in  Fig.  100. 

First,  by  means  of  a  small  dowel,  made  by  soft-soldering  a  piece 
of  the  wire  G  into  the  end  of  the  sheath,  which  is  made  to  rest  in  a 
pit  in  the  anchor  tooth,  as  in  A. 


COMBINATIONS    OF    APPLIANCES.  1 19 

Second,  by  means  of  a  similar  dowel  made  to  engage  a  tube  R 
soldered  to  the  anchor  band,  as  at  C.  In  this  way  the  length  of  the 
sheath  may  also  be  increased  in  the  rare  instances  where  a  longer 
sheath  may  be  required. 

Third,  by  means  of  a  spur  made  from  the  wire  G  soldered  to  the 
anchor  band,  over  which  the  end  of  the  sheath  of  the  jack-screw  may 
be  slipped,  as  in  B. 

Fourth,  by  pointing  the  end  of  the  sheath  with  a  file  and  letting 
the  point  rest  in  a  tube  on  the  anchor  band,  as  in  D. 

Fifth,  by  soldering  the  sheath  directly  to  the  anchor  band,  as  in 
E  and  F. 

Sixth,  by  notching  the  end  of  the  sheath,  and  resting  it  against  a 
wire,  as  in  G. 

Seventh,  by  soldering  the  end  of  the  sheath  directly  to  another 
sheath,  as  in  H. 

Eighth,  by  means  of  a  spur  made  from  the  wire  G  soldered  to  the 
sheath  and  engaged  with  a  tube  R  soldered  to  the  anchor  band,  as 
in  I. 

Ninth,  by  slipping  the  end  of  the  sheath  over  the  screw  of  an 
anchor  band,  as  in  J. 

Of  these  various  ways  of  attaching  the  sheath,  those  shown  in  B, 
E,  F,  and  J,  are  preferable. 

The  point  of  the  jack-screw  is  held  firmly  in  position  in  six  prin- 
cipal ways,  as  shown  in  Fig.  101. 

First,  by  engaging  a  notch  in  its  end  with  a  similar  notch  in  the 
united  ends  of  the  band,  as  at  A,  the  notches  to  be  made  with  a 
separating  file. 

Second,  by  pointing  the  end  of  the  screw  and  engaging  it  with 
small  tubes  R  soldered  to  the  band,  as  at  B. 

Third,  by  a  mortise  in  the  band  to  engage  the  point  of  the  screw, 
as  in  C. 

Fourth,  by  an  elliptical  ring  soldered  to  the  band,  as  in  D,  and 
engaging  the  point  of  the  screw. 

Fifth,  by  means  of  a  staple  soldered  to  the  band,  as  in  E,  and 
engaging  the  notched  point  of  the  screw. 

Sixth,  by  resting  the  screw,  suitably  pointed,  in  a  pit  formed  in 
the  enamel,  or  in  a  filling,  as  in  F. 

Of  these  various  ways  those  shown  in  D  and  E  are  preferred. 

Fig.  1 02  shows  the  jack-screw  effecting  the  labial  movement  of 


I2O 


MALOCCLUSION. 


the  upper  cuspid  teeth,  which  are  provided  with  plain  bands  ce- 
mented upon  their  crowns.  To  the  mesio-lingual  angle  of  one  is 
soldered  a  spur  which  engages  the  base  of  the  sheath  of  the  jack- 
screw  (as  in  B,  Fig.  100),  while  the  notched  point  of  the  screw  en- 


FIG.  102. 


gages  a  staple  soldered  to  the  mesio-lingual  angle  of  the  other  cus- 
pid. By  tightening  the  nut  the  teeth  are  moved  in  opposite  direc- 
tions. The  tubes  R,  in  anticipation  of  reinforcing  anchorage,  are 
also  shown, — one  upon  the  side  of  the  sheath  of  the  screw,  the  other 
upon  the  lingual  surface  of  a  band  encircling  the  first  bicuspid.  As 
the  right  cuspid  will  probably  be  moved  into  position  first  its  further 


COMBINATIONS    OF   APPLIANCES.  121 

progress  will  be  arrested,  as  well  as  its  anchorage  reinforced,  by  a 
ligature  inclosing  the  reinforcement  tubes,  drawn  tight  and  the  ends 
twisted. 

Tubes  R  soldered  to  the  labial  surfaces  of  the  bands  upon  the 
moving  teeth  are  also  shown.  These  are  in  anticipation  of  reten- 
tion by  means  of  a  section  of  the  wire  G  to  be  slipped  through  them, 
its  ends  to  bear  against  the  labial  surfaces  of  the  adjoining  teeth,  as 
described  in  the  chapter  on  Retention. 

Fig.  103  shows  a  combination  in  which  the  jack-screw  is  made 
to  exert  force  in  moving  labially  an  inlocked  cuspid.  The  point  of 
the  screw  engages  a  pit  in  the  enamel,  the  base  of  the  sheath  having 

FIG.  103. 


been  previously  slipped  over  a  spur  (B,  Fig.  100)  soldered  to  the 
mesio-lingual  surface  of  the  anchor  band  No.  i  clamped  upon  the 
first  bicuspid.  Reinforcement  of  the  anchorage  was  gained  by 
means  of  a  section  of  the  G  wire,  the  ends  of  which  were  hooked 
into  tubes,  one  being  soldered  near  the  base  of  the  jack-screw,  the 
other  upon  the  mesio-lingual  angle  of  a  band  encircling  the  lateral 
incisor.  Later  experience  has  proved  that  an  easier  and  better  way 
of  attaching  the  reinforcement  wire  is  to  omit  the  tube  from  the 
band,  soldering  the  straight  end  of  the  wire  directly  to  the  band. 
The  other  end  of  the  wire,  before  bending,  is  passed  straight 
through  the  tube  in  the  direction  of  the  anchor  tooth,  then  bent 
around  in  the  direction  of  the  point  of  the  screw  and  the  surplus 
wire  cut  off.  The  bending  of  the  wire  should  be  the  last  part  of 
the  operation,  or  after  the  cementing  of  the  band  upon  the  lateral 
and  complete  adjustment  of  the  screw. 


122 


MALOCCLUSION. 


A  modification  of  a  similar  combination  of  the  jack-screw  is 
shown  in  Fig.  104,  in  the  labial  movement  of  an  inlocked  lateral, 
the  point  of  the  screw  engaging  a  staple  on  the  lingual  surface  of 
a  band  on  the  malposed  tooth.  The  base  of  the  screw  engages  a  spur 
on  the  anchor  band.  Reinforcement  of  the  anchorage  was  gained 
by  a  loop  made  from  the  wire  G  which  engaged  a  tube  R  soldered  at 
right  angles  to  the  sheath  of  the  screw  on  its  palatine  surface.  The 


FIG.  104. 


G, 


-NO.  2 


ends  of  the  wire,  bent  in  the  form  of  hooks,  engage  wire  ligatures 
encircling  cuspid  and  central  incisor.  This  combination  is  quickly 
and  easily  made,  and  the  reinforcement  through  the  ligatures  is  quite 
as  efficient  as  would  be  if  bands  were  used,  which,  besides  requiring 
more  time  and  trouble  in  adjusting,  would  occupy  valuable  space. 
Of  course  such  ligature  reinforcement  would  be  useless  with  fibrous 
ligatures,  as  slipping  and  stretching  would  render  them  inoperative. 
Fig.  105  shows  a  combination  of  the  jack-screw  where  reciprocal 


COMBINATIONS    OF    APPLIANCES. 


123 


anchorage  was  used  to  accomplish  the  lingual  movement  of  the 
lateral  and  labial  movement  of  the  cuspid,  the  sheath  of  the  jack- 
screw  being  cut  short  to  allow  it  to  travel  forward  over  the  spur  as 
the  nut  was  turned  until  its  base  finally  rested  against  the  anchor 
band,  when  the  lateral  was  drawn  into  place  and  reinforced  the 
anchor  tooth  in  resisting  the  moving  cuspid. 

The  extra  tube  on  the  sheath  of  the  jack-screw  was  in  anticipa- 
tion of  further  reinforcement  of  anchorage,  if  it  should  be  found 
necessary,  by  hooking  another  piece  of  the  wire  G  into  the  tube 
after  soldering  the  other  end  to  a  band  upon  the  first  bicuspid.  It 
was  not  found  necessary  in  this  instance,  but  it  is  always  well  to 
anticipate  the  possible  need  of  spurs,  tubes,  etc.,  in  order  to  avoid 
the  trouble  of  removal  and  readjustment  of  appliances,  the  evil  ef- 
fects of  relinquishment  of  pressure,  etc. 

FIG.  106. 


Fig.  106  represents  a  combination  of  two  jack-screws  for  moving 
labially,  out  of  inlock,  two  central  incisors  (one  also  being  in  torso- 
occlusion),  the  patient  being  a  child  eight  years  of  age.  The  inci- 
sors were  encircled  by  plain  bands,  the  union  of  the  bands  being  at 
their  disto-lingual  angles  and  notched  (as  in  A,  Fig.  101)  to  hold 
a  straight  section  of  the  wire  G,  against  which  rested  the  notched 
points  of  the  jack-screws.  The  bases  of  the  sheaths  were  slipped 
over  the  ends  of  the  screws  of  the  anchor  clamp  bands  (as  in  J, 
Fig.  100)  and  force  was  exerted  by  tightening  the  nuts  of  the  jack- 
screws.  Rotation  of  the  central  was  accomplished  at  the  same  time, 
by  occasionally  tightening  the  wire  ligature  (A,  Fig.  63)  encircling 
the  tooth,  its  looped  ends  engaging  the  wire  and  union  of  the  band. 


124  MALOCCLUSION. 

Retention  was  effected  principally  by  the  occlusion  with  the  lower 
teeth,  the  bands,  however,  having  been  removed  and  soldered  at 
points  of  contact  and  re-cemented  in  position. 

In  using  the  jack-screw  it  is  always  best  to  employ  as  long  a 
sheath  as  possible,  turning  the  nut  close  up  to  the  chisel  end,  in 
order  that  there  may  be  ample  length  of  the  screw  to  effect  the 
necessary  movement.  Formerly  some  annoyance  was  occasioned 
by  the  nut  being  loosened  by  the  tongue.  This  is,  happily,  now 
wholly  overcome  by  the  latest  improvement  to  the  jack-screw, — the 
extension  flange  or  friction  sleeve,  as  already  described. 

Two  sheaths  are  provided  for  the  jack-screws,  to  afford  ample 
length  for  all  cases.  They  should,  of  course,  be  cut  shorter  if  the 
case  demand.  The  author  has  occasionally  found  it  necessary  to 
use  this  screw  and  sheath  combined  only  one-fourth  of  an  inch  in 
length,  as  might  be  found  necessary  in  restoring  to  an  upright  posi- 
tion a  molar  which  had  inclined  into  the  space  made  vacant  by  the 
loss  of  another  tooth. 

Lever. — In  the  movement  of  rotation  of  a  single  lateral  incisor 
by  means  of  the  lever  L,  shown  in  Fig.  107,  the  plain  band,  with  a 

FIG.  107. 


tube  on  its  mesio-labial  angle,  was  cemented  upon  the  lateral.  One 
end  of  the  lever  engaged  the  tube,  the  other  end  being  sprung 
around  and  made  to  engage  a  hook  on  the  buccal  surface  of  an 
anchor  band  on  the  second  bicuspid,  which  was  reinforced  by  a 
section  of  the  wire  G  passed  through  the  tube  R  on  its  lingual  sur- 
face, the  ends  of  the  reinforcement  wire  being  made  to  bear  against 
the  lingual  surfaces  of  the  first  molar  and  the  first  bicuspid. 

Additional  reinforcement  may  often  be  gained  by  ligatures  made 
to  encircle  lever  and  teeth  intervening  between  the  moving  tooth  and 


COMBINATIONS    OF    APPLIANCES.  125 

the  main  anchor  tooth.  The  lever  should  be  occasionally  removed 
and  straightened  to  intensify  the  force.  The  various  sizes  of  the 
levers  furnish  ample  range  for  the  needs  of  larger  teeth,  but  as  the 
force  exerted  by  the  lever  is  so  great  the  smallest  sizes  are  usually 
preferable. 

Fig.  108  shows  a  combination  of  the  lever  for  rotating  a  central 
and  lateral  incisor  and  moving  labially  a  lateral  incisor.  The  re- 
sistance end  of  the  lever  is  passed  through  a  tube  R  soldered  to  the 
disto-lingual  angle  of  a  band  on  the  lateral.  The  power  end,  bent 
in  the  form  of  a  hook,  is  secured  by  a  wire  ligature  made  to  engage 

FIG.  108. 


the  nut  on  the  anchor  band  on  the  first  molar.  This  is  the  author's 
favorite  method  of  securing  this  end  of  the  lever,  as  the  strongest 
anchorage  and  greatest  control  of  the  lever  are  thus  secured. 

Additional  force  is  applied  to  the  rotating  lateral  by  allowing  the 
end  of  the  lever  to  bear  against  the  labial  surface  of  the  cuspid,  and 
it  is  further  intensified  by  an  intervening  wedge  of  rubber.  At  the 
same  time  the  other  lateral  is  being  moved  from  lingual  occlusion 
and  the  central  rotated  by  means  of  wire  ligatures,  band,  and  spur, 
as  would  be  similarly  employed  if  the  expansion  arch  were  used  in- 
stead of  the  lever. 

Fig.  109  shows  a  combination  where  two  levers  were  used  in 
rotating  two  superior  cuspids,  the  ends  of  the  levers  engaging  tubes 
R  soldered  to  bands  upon  the  moving  teeth.  The  power  ends  of 
the  levers  engaged  hooks  soldered  to  an  anchor  band  upon  the  first 
molar,  the  anchorage  being  reciprocal. 


126 


MALOCCLUSION. 


Fig.  no  shows  two  central  incisors  being  rotated  in  opposite 
directions  at  the  same  time  by  means  of  the  lever.  Upon  the  in- 
cisors have  been  cemented  plain  bands  having  soldered  at  their 
disto-labial  angles  tubes  R.  One  end  of  a  section  of  the  smallest 
size  of  lever  wire  was  inserted  into  one  tube  and  then  into  the  other 
by  springing  and  sliding,  as  a  door-bolt  is  slid  into  position. 

FIG.  109. 


FIG.  no. 


FIG.  in. 


Fig.  in  shows  a  view  from  the  labial  aspect  of  the  appliance  in 
position.  The  spring  of  the  wire  exerts  pressure  lingually  on  the 
mesial  angles,  while  the  ends  of  the  lever  operate  in  the  opposite 
direction  on  the  distal  angles  of  the  teeth.  As  the  teeth  are  turned 
it  may  be  necessary  to  occasionally  remove  the  lever  and  straighten 
it  in  order  to  maintain  the  pressure.  Should  one  tooth  be  rotated 
sufficiently  before  the  movement  of  the  other  is  complete,  its  further 
movement  should  be  arrested  by  a  spur  soldered  to  the  disto-lingual 
angle  of  its  bands  and  made  to  bear  against  the  lateral  incisor.  If 


COMBINATIONS    OF    APPLIANCES.  127 

.the  teeth  show  a  tendency  to  separate  as  they  rotate,  this  should  be 
prevented  by  a  wire  ligature  which  should  inclose  the  ends  of  the 
lever  on  the  labial  surface. 

Although  this  is  a  simple  and  efficient  method  of  performing 
double  rotation  of  the  incisors,  yet  it  must  be  remembered  that  in 
most  instances  these  positions  of  the  teeth  are  only  the  result  of 
lateral  pressure  from  narrowing  of  the  arch,  which  must  be  widened 
to  provide  room  for  their  occupancy.  In  such  cases  the  expansion 
arch  is  better  suited  for  accomplishing  the  movement  of  double  ro- 
tation of  the  incisors  while  widening  the  arch  at  the  same  time,  yet 
where  there  is  sufficient  room  for  the  incisors  it  would  be  difficult 
to  find  a  more  ideal  method  than  the  use  of  the  lever,  as  here  de- 
scribed. This  would  be  peculiarly  true  in  cases  where  the  teeth 
after  regulation  by  enlargement  of  the  arch  have,  from  neglect  or 
enforced  absence  of  patients,  partially  relapsed  into  their  former 
malpositions  during  the  period  of  retention. 

FIG.  112. 


E.H.  A. 


When  opposite  movements  of  incisors  in  double  rotation  shall  be 
found  necessary  it  may  be  accomplished  by  means  of  the  lever  L, 
made  to  rest  in  notches  in  sections  of  the  wire  G  soldered  to  the 
disto-labial  angles  of  the  bands,  while  a  wire  ligature  encircling 
spurs  soldered  to  the  mesio-lingual  angles  passes  between  the 
teeth  to  inclose  the  center  of  the  lever,  as  in  Fig.  112.  The  ligature 
should  occasionally  be  tightened  by  twisting.  After  the  teeth  have 
been  sufficiently  rotated,  temporary  retention  may  be  effected  by 
means  of  a  ligature  inclosing  the  spurs  only. 

Traction  Screw. — Although  there  are  many  possible  combinations 
with  the  traction  screw,  yet  in  reality  its  uses  should  be  limited  to 
two,  or  possibly  three.  Its  most  important  use  is  that  of  retraction 
of  that  most  obstinate  tooth,  the  cuspid,  as  shown  in  Fig.  1 13.  This 
it  accomplishes  so  easily  and  so  perfectly,  when  properly  adjusted 
and  managed,  that  it  easily  takes  rank,  we  believe,  over  all  other 
appliances  for  this  purpose.  We  shall  use  this  combination  many 


128 


MALOCCLUSION. 


times,  singly  or  with  other  appliances,   in  the  pages  that  are  to 
follow,  and  will  here  only  describe  its  correct  adjustment. 

The  cuspid  and  anchor  teeth  are  carefully  banded  after  the  man- 
ner described  for  adjustment  of  the  plain  and  anchor  bands  in  the 
chapter  on  Band-making.  The  traction  screw  is  then  held  in 
position,  and  the  short  and  long  sheaths  made  to  touch  the  bands  at 
the  exact  points  they  are  to  occupy  when  soldered.  With  a  suitable 
instrument  the  anchor  band  is  scratched  parallel  with  the  long  tube 
to  indicate  its  alignment.  The  side  of  the  long  sheath  is  then  filed 
to  permit  of  close  contact  with  the  band  and  to  give  increased  sur- 
face for  the  solder,  filing  through  being  carefully  avoided.  The 
band  is  then  replaced,  and  the  exact  point  of  contact  of  the  edge  of 
the  short  sheath  with  the  band  on  the  cuspid  is  located  and  indicated 


FIG.  113. 


A  Y 


E.H.A.          'H 


No.2 


by  a  suitable  mark.  Lest  this  be  obliterated  upon  soldering,  the 
band  may  be  perforated  at  this  point  with  a  small  drill.  Having 
noted  as  accurately  as  possible  the  angle  at  which  this  tube  shall 
stand  to  properly  line  with  the  right  angle  of  the  shaft,  minute 
notches  are  made  in  the  edge  of  the  band  mesially  and  distally,  to 
line  with  the  end  of  the  tube,  Fig.  114.  The  bands  are  now  re- 
moved from  the  teeth  and  the  sheaths  from  the  screws,  and  a  minute 
piece  of  solder  partially  fused  upon  the  edge  of  the  short  tube  at  the 
point  intended  for  attachment  to  the  band.  The  tube  is  then  held 
with  the  solder-placing  pliers,  Fig.  67,  in  the  left  hand,  the  band 
being  held  by  its  untrimmed  ends  in  the  right  hand,  the  end  of  the 
tube  lining  with  the  notches  A  and  B,  Fig.  1 14,  and  the  solder  fused 
by  contact  with  the  flame  at  the  proper  point.  Only  sufficient  solder 
to  form  the  union  should  be  used. 

A  little  experience  will  enable  the  operator  to  make  this — the 
most  difficult  of  all  attachments  in  this  system — easily  and  quickly, 
yet  it  is  highly  essential  that  the  tube  shall  be  attached  at  the  right 


COMBINATIONS    OF    APPLIANCES.  129 

point  and  at  the  proper  angle,  or  the  angle  of  the  screw  will  not  fit. 
The  beginner  may,  therefore,  probably  better  temporarily  wax  the 
tube  in  position  and  invest  and  solder  as  he  would  in  attachments  to 
be  made  in  bridge-  or  crown-work. 

Be  it  remembered  that  the  tube  attached  to  the  cuspid  band  must 
always  stand  at  right  angles  to  the  long  axis  of  the  tooth,  that  a 
free  hinge-like  movement  of  the  tooth  in  retraction  may  be  gained ; 
not  parallel  with  the  long  axis,  as  some  will  persist  in  attaching  it, 
with  resultant  binding  and  prevention  of  free  movement. 

FIG.  114. 


A 


The  surplus  ends  of  the  bands  are  now  trimmed  off  and  smoothed, 
and  the  band  deoxidized  and  cemented  in  position.  While  the 
cement  is  hardening  the  long  sheath  is  soldered,  according  to  align- 
ment, to  the  No.  2  band,  using  plenty  of  solder, — a  piece  one-fourth 
of  an  inch  square  and  of  the  usual  sheet  thickness.  It  is  then 
cleansed  and  slipped  upon  the  screw  and  the  nut  adjusted,  the  angle 
is  hooked  into  the  tube  upon  the  cuspid  band,  and  the  clamp  slipped 
over  the  crown  of  the  molar  and  gently  tightened.  It  is  allowed  to 
remain  a  day  or  two  before  cementing,  in  order  that  this  operation, 
so  important  to  thoroughly  perform,  may  be  accomplished  without 
interference  by  pressure  from  the  approximal  teeth,  and  also  that 
both  the  cuspid  and  the  anchor  tooth  may  slightly  move  and  become 
more  perfectly  adjusted  to  their  relations  with  the  two  bands. 

The  proper  length  of  the  screw  having  been  determined,  it  is  cut 

10 


130  MALOCCLUSION. 

off  behind  the  nut.  Never  shorten  the  screw  and  then  attempt  to 
screw  the  nut  upon  it.  Heat  must  in  no  instance  come  in  contact 
with  any  portion  of  the  shaft  of  the  screw. 

Before  finally  cementing  the  band  in  position,  it  should  be  re- 
moved and  cleansed  and  dried.  The  crown  of  the  molar  should  also 
be  thoroughly  cleansed  and  dried,  the  final  cleansing  being  with  a 
pledget  of  cotton  moistened  with  alcohol  or  ether.  The  crown  being 
properly  protected  from  moisture,  cement  is  quickly  mixed  to  the 
proper  consistence  and  the  interior  of  the  band  nearly  filled.  The 
angle  of  the  traction  screw  is  then  inserted  into  the  short  tube  and 
the  anchor  band  and  cement  carried  down  over  the  crown  with  the 
thumb  and  finger,  forcing  the  cement  well  down  about  the  crown  by 
pressure  from  the  thumb.  The  band  is  quickly  worked  to  the  de- 
sired position,  and  the  nut  of  the  band  tightened  until  it  is  firmly 
clamped.  The  superfluous  cement  is  then  wiped  off  and  the  patient 
dismissed  until  the  next  sitting  before  tightening  of  the  nut  of  the 
traction  screw  is  begun,  in  order  that  the  cement  shall  become 
thoroughly  set  and  the  most  rigid  possible  attachment  gained. 

If  the  operation  so  far  has  been  carefully  performed,  the  nearest 
approach  to  stationary  anchorage  will  have  been  gained,  so  that 
the  cuspid  may  be  moved  distally  without  changing  the  relation  of 
the  occlusal  planes  of  the  anchor  tooth  with  those  of  the  opposite 
jaw.  It  is  very  important,  however,  not  to  strain  the  attachment 
by  overtightening  the  nut  of  the  traction  screw  at  any  time.  One- 
half  a  revolution  of  the  nut  each  day,  or  just  enough  to  exert  a 
slightly  snug  feeling  upon  the  cuspid,  is  all  the  force  that  should 
be  exerted  at  any  one  time. 

Very  often  patients  may  be  provided  with  wrenches  and  intrusted 
to  tighten  the  nut  regularly  each  day  themselves.  This  movement, 
of  all,  however,  should  be  conducted  with  the  greatest  regularity, 
and  unless  the  patient  can  thoroughly  comprehend  and  carry  out 
instructions  he  should  not  be  depended  upon. 

It  is  nearly  always  best  to  operate  the  screw  on  the  outside  of 
the  arch,  placing  the  tube  engaging  the  angle  of  the  screw  in  the 
region  of  the  mesio-lingual  angle  of  the  tooth,  or  in  the  same  man- 
ner as  shown  on  the  right  of  Fig.  115. 

It  is  very  important  that  the  angle  of  the  screw  be  passed  into  the 
tube  its  full  length,  otherwise  it  will  be  broken  when  force  is 
exerted. 


COMBINATIONS    OF    APPLIANCES. 


If  it  is  desired  to  rotate  the  cuspid  as  it  is  moved  distally,  it  may 
be  accomplished  by  using  a  staple  instead  of  a  tube  for  engaging 
the  angle  of  the  traction  screw,  as  shown  on  the  left  of  Fig.  115. 
In  this  instance  the  angle  of  the  screw  is  parallel  with  the  long  axis 
of  the  tooth,  instead  of  at  right  angles  to  it,  as  when  the  tube  is 

FIG.  115. 


used.     In  this  manner  force  is  exerted  on  one  side  of  the  band  only, 
and  rotation,  as  well  as  retraction,  takes  place. 

In  some  instances  it  may  be  desirable  to  operate  the  screw  on  the 
lingual  side  of  the  arch,  as  in  Fig.  116,  although  the  anchorage  is 
not  so  secure  on  account  of  the  shape  of  the  crown  not  admitting 
of  so  strong  attachment  of  the  tube  to  the  band.  The  shifting  of  the 
cuspid  lingually  or  labially  in  its  distal  movement  may  be  accom- 
plished by  bending  the  screw  where  it  enters  the  sheath,  as  in  Fig. 


132 


MALOCCLUSION. 


117.  As  the  nut  is  tightened  the  screw  is  gradually  straightened 
as  it  is  drawn  into  the  sheath,  thus  arranging  the  teeth  in  proper 
alignment. 

A  method  of  reinforcing  the  anchorage  is  also  shown  in  this 
engraving,  by  enlisting  the  resistance  of  the  lateral  incisor.  The 
tooth  is  banded  and  provided  with  one  of  the  tubes  R  soldered  at 
its  disto-lingual  angle,  which  engages  a  straight  section  of  the  wire 
G,  the  other  end  resting  in  another  tube  R  soldered  at  an  obtuse 
angle  near  the  end  of  the  sheath.  The  fine  adjustment  of  this  wire 
may  be  effected  by  means  of  the  regulating  pliers. 

FIG.  117. 


FIG.  118. 


Fig.  1 18  shows  the  use  of  a  traction  screw  in  effecting  rotation  of 
a  bicuspid  tooth,  in  combination  with  the  clamp  bands  Nos.  I  and  2. 
The  angle  of  the  screw  engages  a  staple  made  of  the  G  wire  soldered 
to  the  mesio-lingual  angle  of  the  band  encircling  the  bicuspid. 
By  tightening  the  nut  at  A  traction  force  is  exerted  on  one  side 
only,  while  resistance  in  the  opposite  direction  is  offered  by  the 
intervening  bicuspid. 

It  is  necessary  in  the  treatment  of  many  cases  to  rotate  one  or 
more  of  the  bicuspid  teeth  in  order  to  gain  the  full  size  of  the 
arch,  so  that  it  shall  harmonize  with  the  other  arch  and  establish 
normal  relation  of  the  occlusal  planes.  It  is  also  well  known  that 


COMBINATIONS    OF    APPLIANCES.  133 

rotation  of  these  teeth  is  difficult  by  ordinary  methods.  This 
method  of  rotation  is  very  efficient  and  most  desirable  in  all  such 
cases. 

In  Fig.  119  is  shown  another  use  of  the  traction  screw,  in  ef- 
fecting the  labial  movement  of  a  lateral  and  at  the  same  time  pro- 
viding space  for  its  movement.  A  strip  of  band  material  F  is 
looped  around  the  lateral,  the  ends  resting  on  the  labial  surfaces  of 
the  adjoining  teeth.  To  one  end  is  soldered  vertically  one  of  the 
short  tubes  D,  while  on  the  other  end  is  a  similar  tube  attached 
horizontally.  Into  these  tubes  the  traction  screw  is  placed,  being 
bent  to  conform  to  the  proper  curve  of  the  arch,  and  pushes  the 
ends  of  the  band  farther  apart  as  the  nut  is  tightened. 

FIG.  119. 


Although  efficient,  it  requires  frequent  tightening,  and  is  trouble- 
some on  account  of  its  liability  to  work  loose.  It  is  now  rarely 
used  by  the  author  except  in  the  quick  readjustment  of  teeth  which 
have  partially  relapsed  toward  their  original  malpositions  through 
accident  during  the  period  of  retention. 

Expansion  Arch:  History  and  Combinations. — Its  wide  range 
of  application  in  tooth-movement  easily  distinguishes  the  expansion 
arch,  with  its  attachments  of  bands,  spurs,  and  ligatures,  as  shown 
in  Fig.  1 20,  as  the  most  universal  of  all  regulating  appliances.  Not 
only  may  it  be  used  for  the  movement  of  teeth  singly,  but  also  col- 
lectively, and  it  is  equally  applicable  to  both  arches. 

In  its  use  it  is  made  to  occupy  a  position  external  to  the  dental 
arch,  lying  in  more  or  less  close  proximity  to  the  labial  and  buccal 
surfaces  of  the  teeth,  as  shown  in  Fig.  121.  The  ends  of  the  arch 
are  supported  by  the  accurately  fitting  tubes  of  the  strong  anchor 
bands.  The  front  of  the  arch  is  firmly  supported  by  resting  in 
niches  formed  for  this  purpose  in  the  united  ends  of  bands  on  one 


134 


MALOCCLUSION. 


or  more  of  the  anterior  teeth,  as  occasion  may  require,  although 
the  brass  wire  ligatures  alone  may  in  some  instances  be  sufficient  for 
its  support  in  this  region. 

In  accomplishing  the  various  tooth-movements  the  expansion 
arch  is  first  made  to  conform  to  the  shape  of  the  ideal  dental  arch, 
or  as  we  wish  the  teeth  to  be  arranged  when  the  movements  are 
completed.  It  therefore  becomes  a  guide  and  pattern  for  the 

FIG.  120. 


FIG.  121. 


E.H.P" 


proper  alignment  of  the  teeth,  as  well  as  the  means  of  effecting 
their  movement  by  reason  of  its  elasticity  and  the  use  of  the  wire 
ligatures.  The  adjustment  of  the  size  of  this  pattern  for  the  re- 
quirements of  the  teeth  to  be  moved  into  proper  alignment  is  con- 
trolled by  the  nuts  in  front  of  the  anchor  tubes. 

For  the  inception  of  this  valuable  device,  as  we  have  said,  we 
are  indebted  to  Fauchard,  who  introduced  it  in  1726.     Unques- 


COMBINATIONS    OF    APPLIANCES. 


tionably  its  introduction  marked  the  most  important  step  in  the 
history  of  regulating  appliances. 

Originally  the  appliance  was  very  crude,  clumsy,  and  unsightly, 
and  its  uses  greatly  limited.     It  was  composed  of  a  flat  ribbon  of 


FIG.  122. 


FIG.  123. 


FIG.  124. 


FIG.  125. 


metal,  perforated  for  the  reception  of  ligatures  by  means  of  which 
attachments  to  the  teeth  used  as  anchorage,  as  well  as  to  the  teeth 
to  be  moved,  were  effected.  It  has  undergone  many  modifications 
by  many  practitioners  since  Fauchard's  time,  only  a  few  of  which 
we  have  here  space  to  consider. 

Four  of  these  are  represented  in  Figs.  122,  123,  124,  and  125. 


136  MALOCCLUSION. 

It  is  doubtful  if  Fox's  plan  of  nearly  a  century  later  was  any  im- 
provement over  Fauchard's.  It  consisted  principally  in  the  addi- 
tion of  that  most  useless  absurdity,  the  gag,  in  the  form  of  blocks 
of  ivory  to  prevent  the  closure  of  the  jaws  and  interference  from 
the  moving  teeth. 

A  marked  improvement  in  the  anchorage  of  the  arch  was  given 
us  by  Schange  in  1841,  in  the  form  of  a  skeleton  crib  attachment 
to  the  molars. 

We  greatly  question  whether  Harris's  supposed  improvement  of 
the  expansion  arch  in  1850  was  an  improvement.  Metal  caps  were 
swaged  to  cover  the  crowns  of  the  molars  to  whick  the  arch  was 
soldered,  and  in  order  to  keep  these  crowns  in  position  Upon  the 
anchor  teeth  they,  in  turn,  were  soldered  to  a  metal  plate  covering 
the  vault  of  the  arch.  This  necessitated  the  frequent  removal  of 
the  device  for  the  purpose  of  cleansing — a  fatal  weakness  in  any 
appliance,  as  the  moving  teeth  are  thus  frequently  sprung  back 
and  forth  by  the  relinquishment  and  reapplication  of  force,  which 
action  is  a  certain  means  of  inciting  inflammation. 

Desirabode's  modification  of  the  expansion  arch  was  very  simi- 
lar to  that  of  Harris. 

To  describe  any  considerable  number  of  the  later  modifications 
would  require  so  much  space  that  the  author  has  thought  it  best  to 
omit  them  all  to  avoid  any  inference  of  invidious  distinction,  their 
characteristics  differing  mostly  in  their  proportions  and  in  their 
manner  of  attachment,  they  being  combined  usually  with  some 
form  of  plate. 

The  author's  improvements  may  be  briefly  said  to  consist  in 
change  of  metal,  modification  of  form  and  proportions,  delicacy 
of  temper,  greater  length  of  threading  of  sides  for  universal  adjust- 
ment of  size,  in  the  material,  style,  and  proportions  of  the  parts 
entering  into  the  anchor  clamp  bands,  and  in  the  various  attach- 
ments, some  of  which  are  modified  and  others  newly  devised.  Im- 
portant among  these  is  the  addition  to  the  clamp  band  of  the  long 
tubular  sheath  for  the  reception  of  the  ends  of  the  arch,  which  not 
only  protects  the  cheeks  from  abrasion  by  the  threaded  portion  of 
the  arch,  but  gives  greater  stability  to  the  anchorage.  Another  is 
the  delicate  style  of  spur  and  means  of  its  attachment  to  the  arch, 
its  use  controlling  the  direction  of  force  exerted  by  the  ligatures. 
Still  others  deemed  very  important  are  the  friction  sleeve  of  the 


COMBINATIONS    OF    APPLIANCES.  137 

nut,  the  wire  ligature  and  the  reinforcement  arch,  descriptions  and 
properties  of  which  follow  in  connection  with  instructions  for 
their  use. 

Unquestionably  the  greatest  modern  improvement  in  connection 
with  the  use  of  the  arch  is  the  adoption  of  wire  for  ordinary 
ligatures,  in  place  of  rubber  and  the  fibers.  (Fourth  edition.)* 
This  improvement  has  greatly  extended  its  range  of  uses,  making 
easy  much  that  was  impracticable  or  even  impossible  before.  Its 
great  strength,  cleanliness,  and  freedom  from  stretching  or  slipping 
place  it  easily  ahead  of  all  other  ligatures.  It  is  easily  and  quickly 
applied,  and  is  unobtrusive  in  size.  Its  most  valuable  quality, 
however,  is  that  it  may  be  tightened  by  twisting,  without  renewal, 
possessing  thereby,  in  addition  [to  its  primary  usefulness,  the 
ideal  power  of  the  screw,  and  obviating  the  necessity  for  relinquish- 
ment  of  pressure  on  the  moving  tooth,  as  must  follow  the  use  of 
other  ligatures.  Its  force  is  direct  and  positive.  It  is  very  im- 
portant, however,  that  only  wire  of  the  proper  metal,  quality,  and 
size  be  used.  After  much  experimenting  brass  has  proved  by  far 
the  most  satisfactory,  the  most  useful  size  being  No.  26.  If 
larger  it  will  be  unyielding;  if  smaller  it  will  not  possess  sufficient 
strength.  It  is  also  important  that  it  shall  be  in  temper  very  soft, 
so  made  during  its  manufacture.  Wire  of  spring  temper  is  entirely 
useless. 

Uses  of  the  Arch. — If  a  single  tooth  is  to  be  moved  buccally  or 
labially,  it  is  effected  by  a  plain  ligature  being  made  to  inclose  it 
and  the  arch  (A,  Fig.  120),  and  being  occasionally  tightened  by 
either  twisting  or  renewal.  If  a  number  of  teeth  are  to  be  moved 
forward  simultaneously,  the  result  is  attained  by  ligating  the  teeth 
to  the  arch  and  tightening  the  nuts  in  front  of  the  anchor  tubes. 

The  wire  being  inexpensive,  a  ligature  of  generous  length  (about 
one  foot)  should  be  employed,  to  afford  a  ready  grasp  for  both 
hands,  that  strong  tension  may  be  exerted  while  giving  it  the 
twist,  which  should  never  be  more  than  three-fourths  of  a  turn  at 
first.  The  surplus  ends  are  then  clipped  off,  leaving  projections 
one-eighth  of  an  inch  long.  These  ends  are  then  curled  under,  as 

*The  author  is  unable  to  find  record  of  any  use  or  mention  of  the  wire 
ligature  in  connection  with  the  expansion  arch  previous  to  his  introduction 
of  it  in  1895,  although  he  had  thoroughly  tested  its  value  for  two  years  be- 
fore publication. 


138  MALOCCLUSION. 

shown  correctly  in  Figs.  120  and  126.  It  is  very  important  that 
this  point  be  remembered,  for  by  observing  this  special  way  of  pro- 
viding for  the  sharp  ends  a  smooth,  easy  surface  is  presented 
to  the  lip.  Never  attempt  to  bend  the  twisted  portion  of  the  liga- 
ture out  of  the  way,  as  by  so  doing  the  entire  strain  would  be 
brought  on  one  strand  and  the  ligature  in  almost  every  instance  be 
broken. 

In  tightening  the  ligature  a  very  excellent  plan  is  to  firmly 
press  the  tooth  and  arch  between  the  thumb  and  finger  while  giving 
the  ligature  another  half  turn  with  suitable  pliers.  It  should  be 
remembered  that  the  spring  of  the  wire  arch,  when  used  in  con- 
nection with  the  wire  ligature,  is  constantly  acting,  so  that  as  a  rule 
tightening  of  a  ligature  need  be  done  only  occasionally. 

Rotation  is  accomplished  by  firmly  cementing  to  the  tooth  n 
plain  spurred  band  and  encircling  the  spur  and  arch  with  a 
tightly  drawn  ligature  (B,  Fig.  120),  much  force  being  exerted, 
upon  the  moving  tooth  at  its  diagonally  opposite  corners,  in 
reality  the  arch  operating  as  two  levers  combined,  the  power  ends 
acting  in  opposite  directions.  No  tooth  can  resist  the  combined 
rotating  force  of  these  levers,  while  at  the  same  time  the  relative 
position  of  the  tooth  is  perfectly  controlled. 

Let  us  further  study  some  of  the  uses  of  the  expansion  arch  in 
a  most  complex  case,  Fig.  126,  necessitating  force  from  all  direc- 
tions to  be  exerted  upon  the  badly  malposed  teeth,  and  offering 
the  severest  test  to  a  regulating  appliance. 

The  delicate  wire  loop  lying  lingual  to  the  teeth  will  be  ex- 
plained later. 

The  dental  arch  requires  much  widening,  while  both  centrals  and 
both  laterals  are  to  be  carried  forward  and  outward  and  rotated, 
and  the  cuspids  are  to  be  elevated  in  their  sockets.  It  will  be 
noticed  that  wire  ligatures  are  looped  over  spurs  on  the  disto- 
lingual  angles  of  bands  upon  the  incisors,  thus  exerting  pressure 
as  they  are  occasionally  tightened  by  either  twisting  or  renewal. 
This  tends  to  rotate  the  teeth,  as  well  as  move  them  forward  and 
outward  into  harmony  with  the  pattern  of  the  expansion  arch. 
The  exact  direction  of  this  force  is  controlled  by  little  spurs  at- 
tached by  soft  solder  at  the  desired  points  to  the  expansion  arch, 
which  thus  prevent  the  ligatures  from  slipping  down  the  sides  of 
the  arch,  as  is  clearly  shown  in  the  engraving.  (See  also  chapter 


COMBINATIONS    OF    APPLIANCES.  139 

on  Soldering.)  The  nuts  in  front  of  the  anchor  tubes  are  occa- 
sionally tightened  as  more  room  for  the  moving  teeth  is  re- 
quired, thus  carrying  all  four  teeth  forward  with  the  positive  force 
of  the  screw.  The  action  is  practically  that  of  two  jack-screws 
united. 

As  the  expansion  arch  is  very  elastic,  it  exerts  a  powerful  lateral 
force  upon  the  sides  of  the  dental  arch,  through  the  anchor  bands 
and  the  ligatures  upon  the  bicuspids.  By  studying  this  figure  it 


will  be  seen  how  perfectly  force  is  being  distributed  to  accomplish 
these  various  tooth  movements,  and  how,  as  in  all  fine  mechanisms, 
each  part  assists  and  harmonizes  with  each  other  part.  For  ex- 
ample, note  how  perfectly  the  force  is  reciprocated  from  one  mov- 
ing tooth  to  another,  or  from  one  lateral  half  of  the  arch  to  the 
other,  and  how  this  is  intensified  by  the  pressure  on  the  center  of 
the  arch  in  front,  the  tendency  being  when  pressure  is  exerted  at 
this  point,  as  in  all  arches,  to  widen  the  lateral  halves.  One  lateral 
incisor  reciprocates  its  force  to  the  other,  one  central  to  the  other, 
all  in  perfect  harmony. 

Note  also  what  complete  control  we  have  over  the  teeth,  singly 
or  collectively.  As  we  shall  see  later,  in  the  'Treatment  of  Cases," 
we  may  widen  the  arch  on  one  or  both  sides,  or  we  may  lengthen 
one  or  both  of  the  lateral  halves  or  any  portion  of  them.  This 


140  MALOCCLUSION. 

appliance  is  not,  hozvever,  suited  for  narrowing  or  shortening  the 
arch  or  cither  of  its  lateral  halves. 

The  modifications  of  form  and  directions  of  spring,  plus  the 
modifications  in  ligature  attachments,  make  it  possible  to  derive 
wonderful  combinations  and  results,  and  in  its  use  it  is  possible 
to  cultivate  a  very  high  degree  of  skill.  It  typifies  efficiency  and 
simplicity.  It  is  easily  applied,  and  is  so  stable  in  its  attachment 
that  there  need  be  no  slipping  or  loss  of  power.  It  is  cleanly,  and 
occupies  a  position  in  the  mouth  that  is  of  the  least  inconvenience 
to  the  patient.  If  this  device  be  intelligently  managed  it  need 
interfere  but  little  with  the  normal  functions  of  the  mouth.  On  the 
contrary,  if  improperly  managed  it  becomes  a  constant  annoyance 
and  one  of  the  most  wobbly  and  useless  of  devices. 

In  its  proper  use  the  widest  range  for  reciprocal  anchorage 
is  possible.  \Ye  may  also  gain  simple,  and  a  considerable  degree 
of  stationary,  anchorage  by  reason  of  the  tubes  and  firm  attach- 
ment of  the  anchor  bands  to  the  teeth  used  as  anchorage. 

The  necessary  direction  and  distribution  of  force  should  be 
carefully  studied  in  each  case,  as  well  as  the  effect  upon  the 
anchor  teeth  and  all  that  are  in  proper  position. 

The  arch  should  always  be  made  to  lie  approximately  close  to 
the  teeth,  so  as  to  interfere  as  little  as  possible  with  the  functions 
of  the  lips. 

Again,  as  its  force  in  tooth  movement  is  exerted  usually  by  its 
elasticity,  its  careful  bending,  in  order  to  secure  the  proper  de- 
gree and  direction  of  force,  is  of  much  importance.  To  make 
the  most  of  this  possibility,  and  at  the  same  time  avoid  interference 
with  desired  movements  or  with  teeth  already  in  correct  position 
by  binding,  is  the  most  difficult  problem  in  its  management,  and 
yet  is  easily  solved  if  intelligently  studied  in  each  case. 

The  author's  latest  improvement  to  the  expansion  arch  is  the 
extension  flange,  or  friction  sleeve,  of  the  nut,  which  accurately 
telescopes  the  end  of  the  sheath  ]on  the  anchor  band,  the  shoulder 
of  the  nut  bearing  against  the  end  of  the  sheath,  while  the  end  of 
the  sleeve  bears  against  the  shoulder  formed  by  the  smaller  diam- 
eter of  the  sheath,  as  shown  in  Fig.  127. 

One  of  the  advantages  of  this  style  of  nut  is  greater  length  and 
consequently  greater  strength  of  thread  without  increase  of  bulk, 
but  its  chief  advantage  is  that  it  prevents  the  annoyance  of  the 


COMBINATIONS    OF    APPLIANCES.  14! 

loosening  of  the  nut  by  the  movements  of  the  tongue  and  lips — 
an  annoyance  which  has  existed  as  long  as  small  screws  and  nuts 
have  formed  parts  of  regulating  appliances. 

After  long  and  persistent  experimenting  in  the  use  of  the  arch 
the  author  believes  he  has  succeeded  in  eliminating  all  weaknesses 
and  in  gaining  very  nearly  the  ideal  in  its  size,  proportion,  and 
elasticity,  as  well  as  in  the  size  and  proportionate  strength  of  each 
part  of  the  anchor  bands  for  its  attachment,  Fig.  127.  A  frequent 

FIG.  127. 


mistake  in  the  adjustment  of  the  anchor  bands  is  in  not  placing 
them  in  correct  position  upon  the  crowns  of  the  teeth,  usually  in 
not  forcing  them  sufficiently  over  the  crowns,  in  which  case  they 
will  soon  loosen ;  but  if  properly  placed,  as  in  Fig.  87,  and  thor- 
oughly burnished  and  clamped  to  conform  to  the  surface  of  the 
crown,  displacement  is  impossible.  (See  Directions  for  Setting 
Clamp  Bands  in  Chapter  IX.) 

There  are  two  sizes  of  anchor  bands  used  for  securing  the  ends 
of  the  expansion  arch,  namely,  the  D  and  X  bands.  The  larger 
(D)  are  most  frequently  used,  and  preferably  upon  the  first  molars, 
as  on  account  of  their  superior  size  and  favorable  position  they 


142  MALOCCLUSION. 

ordinarily  afford  by  far  the  best  anchorage.  It  may,  however, 
be  found  desirable  to  employ  one  of  the  bicuspids  for  anchorage, 
and  for  this  purpose  the  band  X  was  added.  The  sheath  is  set 
farther  back,  to  afford  room  for  the  nut  as  the  curve  of  the  arch 
is  reached. 

Occasionally  the  tooth  which  it  is  desired  to  use  as  anchorage 
may  be  found  to  incline  forward  at  such  an  angle  that  the  sheath  on 
the  D  band  will  not  properly  line  with  the  expansion  arch,  in 
which  case  the  band  should  be  removed  and  the  sheath  be  de- 
tached and  resoldered  at  the  proper  angle.  This  may  be  readily 
effected  by  placing  a  small  piece  of  solder  and  borax  at  the  union 
of  the  band  and  sheath,  applying  heat  and  turning  the  band  as 
desired.  It  is,  however,  rarely  necessary,  as  by  slightly  bending  the 
arch  and  shifting  the  band,  it  can  in  most  instances  be  properly 
adjusted  without  changing  the  position  of  the  tube. 

The  proper  alignment  of  the  sheaths  is  best  effected  by  slipping 
the  ends  of  the  arch  into  them  before  firmly  clamping  the  bands. 

In  order  that  the  patient  may  become  gradually  accustomed  to 
the  appliances,  the  bands  should  be  worn  for  two  or  three  days 
loosely  clamped  about  the  teeth,  then  the  arch  added  without 
ligatures  for  three  or  four  days  more,  and  finally  all  carefully  and 
thoroughly  adjusted  and  the  ligatures  applied  for  the  movement  of 
the  teeth.  They  should  be  very  light  of  tension  at  first.  If  this 
bf.  done,  the  patient  will  be  more  tolerant  of  conditions  during  the 
progress  of  the  movement. 

The  elasticity  of  the  arch  is  sufficient  to  exert  ample  force  for 
widening  either  of  the  dental  arches,  yet  in  some  instances  where 
the  patient  has  reached  maturity  the  force  may  not  be  sufficient 
to  accomplish  the  desired  movement  as  rapidly  as  may  be  wished. 
To  meet  this  limitation  we  have  devised  the  reinforcement  arch  L, 
which  should  be  adjusted  to  exert  pressure  upon  the  lingual  sur- 
faces of  the  anchor  bands,  as  in  Fig.  128;  also  Fig.  126.  Attach 
on  each  side  in  the  manner  following:  unite  two  short  tubes  at  right 
angles,  R  and  D;  slip  the  longer  one  over  the  end  of  the  screw 
of  the  clamp  band  D;  bend  the  end  of  the  lever  sharply  at  right 
angles  and  engage  it  with  the  short  tube.  Any  desired  degree  of 
force  may  be  easily  gained  with  this  simple  method  of  reinforce- 
ment. 

A  cheaper  and  quite  as  efficient  way  of  securing  the  ends  of  tha 


COMBINATIONS    OF    APPLIANCES.  143 

reinforcement  spring  is  to  finely  point  the  ends,  bent  sharply  out- 
ward at  right  angles,  and  insert  them  into  fine  perforations 
made  in  the  anchor  bands  at  their  mesio-lingual  angles,  as  in 
Fig.  223.  The  perforations  should  be  made  with  the  finest  pointed 
excavator  or  a  delicate  drill,  made  to  pass  through  the  band  and  a 
little  beyond  by  gently  working  it  between  band  and  enamel.  A 
large  perforation  would  weaken  and  injure  the  band. 

FIG.  128. 


Combinations  of  the  Expansion  Arch  and  Traction  Screw. — As 

we  have  already  stated,  the  expansion  arch  is  not  suited  for  shorten- 
ing the  anterior  part  of  the  dental  arch  or  its  lateral  halves,  for  the 
reason  that  it  is  impossible  to  gain  complete  stationary  anchorage 
in  its  use,  the  spring  of  the  arch  and  attachment  of  ligatures  de- 
feating the  possibility  of  complete  rigidity  of  anchorage  and  ap- 
pliances ;  but  by  combining  it  with  the  traction  screw,  perfect  results 
are  possible. 

Fig.  129  shows  a  very  important  combination  of  the  traction 
screw  and  expansion  arch  for  shortening  one  of  the  lateral  halves 
of  the  arch  and  at  the  same  time  correcting  malpositions  of  teeth. 

The  traction  screw  should  be  first  adjusted  as  already  described, 
and  as  shown  in  Fig.  113.  In  addition  it  should  be  provided  with 
one  of  the  tubes  D  soldered  to  the  side  of  the  sheath  Y  near  its 
mesial  end.  This  is  for  the  reception  and  support  of  one  end  of 
the  expansion  arch  in  place  of  the  usual  D  or  X  band.  The  nut 
of  the  expansion  arch  is  to  bear  against  this  tube,  and  when  so 
used  should  be  reversed,  the  friction  sleeve  turned  mesially.  The 
other  end  of  the  expansion  arch  is  supported  in  the  usual  way,  as 


144  MALOCCLUSION. 

in  Fig.  126.  As  the  cuspid  is  retracted  into  the  space  made 
vacant  by  the  loss  of  the  first  bicuspid  the  malposed  incisors  are 
rotated  by  means  of  the  ligatures,  bands,  and  spurs,  as  is  well 
shown  in  the  engraving,  and  also  in  Fig.  126. 

The  general  control  of  the  incisors  is  gained  by  tightening  or 
loosening  the  nuts  of  the  expansion  arch,  as  in  Fig.  129,  in  accom- 
plishing the  movements  of  the  incisors. 

FIG.  129. 


A  similar  combination  may  be  used  on  the  opposite  side  of  the 
arch  when  it  is  desirable  to  shorten  both  of  the  lateral  halves. 

Similar  combinations  of  the  traction  screw  with  the  B  arch  will 
often  be  found  necessary.  These,  however,  will  be  described  in  the 
treatment  of  cases  belonging  to  Class  II,  Division  i. 

Miscellaneous  Combinations. — Fig.  130  shows  a  combination  for 
widening  and  lengthening  the  arch.  The  notched  ends  of  the  jack- 
screws  engage  a  section  of  one  of  the  levers  L  held  in  position  by 
notches  formed  in  the  united  ends  of  bands  upon  the  lateral  in- 
cisors. The  sheaths  of  the  screws  were  secured  to  anchor  clamp 
bands  No.  2  upon  the  first  molars,  as  in  F,  Fig.  100.  The  incisors 
were  moved  forward  by  turning  the  nuts  of  the  jack-screws,  \vhile 
the  arch  was  widened  by  the  spring  of  a  lever  L,  the  ends  bent 
sharply  at  right  angles  and  made  to  engage  delicate  holes  bored  in 
the  sides  of  the  sheaths  of  the  jack-screws,  all  as  clearly  shown 
in  the  engraving. 

A  modification  of  this  plan  is  to  exert  pressure  laterally  by  means 
of  a  third  jack-screw  in  place  of  the  spring,  this  screw  being 


COMBINATIONS    OF    APPLIANCES.  145 

notched  at  each  end  and  made  to  rest  in  contact  with  the  other 
screws,  anterior  to  their  nuts.  This  plan,  however,  is  rarely  as 
desirable  as  the  first. 

Another  combination  is  shown  in  Fig.  131,  in  which  the  torso- 
labial  movement  of  the  laterals  was  effected  by  means  of  two 
jack-screws  and  two  levers.  The  points  of  the  jack-screws  en- 
gaged mortises  in  bands  on  the  disto-lingual  angles  of  the  laterals, 

FIG.  130. 


their  bases  resting  over  spurred  bands  on  the  anchor  teeth.  As  the 
teeth  were  moved  labially  by  tightening  the  nuts  of  the  screws, 
they  were  also  rotated  by  the  two  levers  L,  which  were  crossed  In 
front.  The  resistance  ends  of  the  levers  were  inserted  in  tubes 
soldered  to  the  labial  portions  of  the  bands.  One  of  the  power 
ends  was  secured  by  being  latched  into  a  hook  soldered  to  the 
buccal  surface  of  one  of  the  anchor  bands,  the  other  being  bent 
sharply  at  right  angles  and  engaging  a  tube  soldered  at  right 
angles  to  the  tube  on  the  band  on  the  opposite  lateral,  thus  exerting 
-  a  certain  amount  of  reciprocal  force.  Although  this  combination  is 


146 


MALOCCLUSION. 


sometimes  useful,  it  is  rarely  as  desirable  as  the  expansion  arch 
would  be  in  such  cases. , 

Another  combination  for  effecting  the  lengthening  of  the  arch 
by  moving  forward  all  of  the  incisors  by  means  of  two  jack-screws, 
the  points  of  which  engage  staples  soldered  to  the  disto-lingual 
angles  of  bands  on  the  lateral  incisors,  is  shown  in  Fig.  132. 

FIG.  132. 


The  necessary  rotation  of  the  incisors  was  accomplished  at  the 
same  time  by  means  of  a  section  of  one  of,  the  levers  L,  sprung 
into  tubes  upon  the  disto-labial  angles  of  the  bands  upon  the 
laterals.  The  central  incisors  were  laced  to  the  lever.  As  the 
nuts  of  the  jack-screws  were  tightened  all  of  the  incisors  were 
carried  forward.  At  the  same  time  they  were  rotated  by  the  elas- 
ticity of  the  lever. 

Fig-  133  shows  a  combination  for  retraction  of  the  cuspid  and 
labial  movement  of  the  lateral  incisors.  While  the  traction  screw 


COMBINATIONS    OF    APPLIANCES. 


147 


was  accomplishing  the  distal  movement  of  the  cuspid  it  was  as- 
sisted by  the  loop  and  traction  screw  device,  as  in  Fig.  1 19,  operat- 
ing upon  the  incisor,  while  the  other  incisor  was  being  moved 
labially  by  means  of  a  jack-screw,  the  base  of  which  rested  over  a 
spur  soldered  to  the  sheath  of  the  traction  screw  operating  upon  the 
cuspid. 

Figs.  134,  135,  and  136  show  simple  and  convenient  methods  of 
moving  single  teeth  that  are  lingually  or  labially  displaced.     In 

FIG.  134. 


FIG.  136. 


Fig.  134  anchorage  is  gained  for  the  force  exerted  by  the  wire  or 
rubber  ligature  by  the  short  sheath  of  one  of  the  jack-screws  being 
slipped  over  the  end  of  the  screw  of  the  No.  2  band  upon  the  first 
molar. 

In  Fig.  135  the  screw  was  lengthened  by  an  additional  piece  of 
metal  soldered  to  its  end. 

In  Fig.  136  a  piece  of  the  wire  G,  or  a  section  of  the  lever  L, 
was  bent  sharply  at  right  angles  and  made  to  engage  a  tube  R 
soldered  to  a  clamp  band  No.  2  upon  the  first  molar. 


148 


MALOCCLUSION. 


Fig.  137  shows  a  method  of  making  a  long  clamp  band  which 
is  sometimes  useful  in  closing  spaces  between  incisors. 

To  the  ends  of  a  section  of  band  material  of  suitable  length  are 
soldered  tubes  D,  one  horizontally  and  one  perpendicularly,  which 
engage  the  angle  and  screw  ends  of  the  traction  screw.  By  tight- 
ening the  nut  the  size  of  the  band  is  diminished  and  force  exerted. 

Figs.  138  and  139  show  efficient  devices  for  widening  the  arch 
in  the  region  of  the  bicuspids.  Force  is  exerted  by  a  lever  L  of 

FIG.  138. 


FIG.  139. 


suitable  length,  its  ends  being  secured  by  engaging  in  tubes 
R,  soldered  at  right  angles  to  sections  of  wire.  G,  which  have  been 
soldered  to  the  lingual  surfaces  of  the  anchor  bands,  as  in  Fig.  138, 
or  in  a  closed-end  tube  attached  directly  to  the  anchor  band,  as  in 
the  left  of  Fig.  139,  or  the  tube  may  be  soldered  to  a  side  of  the 
nut  of  the  clamp  band,  as  on  the  right.  This  form  of  device  is 
often  useful  in  widening  the  arches  of  children  to  release  lateral 
pressure  upon  the  centrals,  to  be  followed  by  a  delicate  vulcanite 
plate  covering  the  vault  of  the  arch,  for  retention,  as  in  Fig.  158. 

A  new  combination  of  appliances  for  effecting  double  rotation  of 
the  central  incisors  is  shown  in  Fig.  140.  It  consists  of  bands 
having  spurs  soldered  at  their  mesio-labial  angles  to  engage  a 


COMBINATIONS    OF    APPLIANCES.  149 

tightly  drawn  and  twisted  wire  ligature.  Between  the  bands  is 
stretched  a  strip  of  rubber.  By  the  occasional  renewing  of  the 
ligature  a  powerful  force  is  exerted  which  will  turn  the  teeth  readily. 
Temporary  retention  is  effected  by  the  application  of  a  fresh  wire 
ligature  and  dispensing  with  the  rubber. 

Fig.  141  represents  a  very  neat  and  convenient  method  of  forc- 
ing the  eruption  of  a  cuspid  which  had  become  impacted  by  the 
too  long  retention  of  the  deciduous  cuspid.  The  first  upper  bicus- 
pid was  encircled  by  a  Xo.  i  band;  to  its  labial  surface,  parallel 

FIG.  140. 


with  the  long  axis  of  the  tooth,  was  soldered  a  tube  R  which  en- 
gaged a  section  of  the  wire  G  bent  sharply  at  right  angles,  the 
other  end  being  flattened  and  bent  to  engage  the  occlusal  edge  of 
the  lateral.  A  common  pin  was  set  in  the  enamel  of  the  impacted 
tooth.  One  had  also  been  soldered  to  the  anchor  wire.  A  ligature 
was  made  to  connect  both  pins,  which  exerted  constant  pressure. 
While  this  simple  and  delicate  device  is  perhaps  the  nearest  to 
the  ideal  for  simple  cases  where  the  forcing  of  the  eruption  of  a 
tooth  that  is  not  greatly  deflected  from  its  normal  incline  is  de- 
sired, yet  in  such  pronounced  cases  of  deflection  as  indicated  by 
Fig.  141  the  anchorage  is  not  sufficient  to  overcome  the  resistance 
necessary  in  turning  a  tooth  so  thoroughly  imbedded  in  such 


I5O  MALOCCLUSION. 

strong  encasement  of  bone.  The  expansion  arch,  as  in  Fig.  273, 
is  better,  and  in  some  cases  even  the  combining  of  all  the  anchorage 
attainable  in  this  manner  with  that  gained  from  occlusal  anchorage, 
as  in  Fig.  97,  is  necessary,  as  we  have  found  in  some  four  or  five 
cases. 


CHAPTER    XII. 

RETENTION. 

AFTER  malposed  teeth  have  been  moved  into  the  desired  positions 
it  is  of  the  greatest  importance  that  they  be  mechanically  supported 
until  all  tendency  to  return  to  their  former  positions  has  subsided, 
but  it  cannot  be  too  strongly  insisted  upon  that  unless  such  occlu- 
sion has  been  established  as  will  enable  the  inclined  planes  of  the 
cusps  to  act  in  harmony  for  mutual  support,  and  unless  perfect  har- 
mony as  to  sizes  of  arches  be  gained,  permanency  of  the  teeth  in 
their  new  positions  after  the  retaining  devices  have  been  removed 
cannot  be  hoped  for.  It  should  be  borne  in  mind  that  all  retaining 
devices  are  only  temporary  assistants  to  the  permanent  establish- 
ment of  the  normal  functions  of  the  occlusal  planes  of  the  teeth. 

Time  Required  for  Retention. — The  time  required  for  mechani- 
cal retention  varies,  according  to  the  age  of  the  patient,  occlusion, 
conditions,  tooth  movements  accomplished,  health  of  tissues,  etc., 
from  a  few  days  to  a  year  or  longer,  while  perhaps  in  rare  instances 
retention  may  be  required  for  an  indefinitely  greater  period.  Upper 
incisors  which  have  been  moved  from  lingual  to  normal  occlusion, 
as  in  Fig.  205,  require  retention  for  a  few  days  only,  as  the  occlu- 
sion with  the  lower  incisors  permanently  supports  them  in  their  new 
positions. 

Again,  the  support  of  teeth  that  have  been  directed  into  cor- 
rect positions  during  the  period  of  eruption  is  usually  required  for 
a  few  months  only,  while  a  much  longer  retention  (for  at  least  a 
year)  would  be  required  for  the  same  teeth  if  moved  after  the  full 
development  of  their  alveoli. 

Again,  owing  to  the  great  disturbance  of  the  fibers  of  the  peri- 
dental  membrane  of  a  tooth  which  has  been  rotated,  its  retention  re- 


RETENTION.  151 

quires  a  far  longer  time  than  if  the  movement  of  elevation  had  been 
accomplished.  A  few  months  for  the  latter  is  sufficient,  where  at 
least  a  year,  and  sometimes  two,  if  the  patient  have  reached  ma- 
turity, may  be  necessary  for  the  former. 

A  rule  of  general  application  may  be  made,  that  twice  as  much 
time  will  be  required  for  retention  of  the  teeth  of  patients  aged 
twenty-one  as  for  those  of  patients  aged  twelve,  the  same  tooth 
movements  having  been  performed. 

There  is  usually  a  temptation  to  remove  the  appliances  before  the 
teeth  have  become  thoroughly  established,  and  many  are  the  failures 
from  this  cause  of  otherwise  well-conducted  cases.  As  so  much 
depends  upon  this  part  of  the  operation,  it  is  far  better  that  the 
appliances  should  be  worn  longer,  even,  than  necessary,  rather  than 
that  they  be  too  early  removed. 

It  should  ever  be  borne  in  mind  that  unless  the  conditions  which 
have  been  operative  in  producing  or  maintaining  malocclusion  be 
removed  or  modified,  the  establishing  of  permanent  normal  occlu- 
sion can  rarely  be  hoped  for.  As  for  example,  if  the  arches  have 
been  narrowed  and  the  teeth  forced  to  take  malpositions  as  a  result 
of  mouth-breathing,  due  to  pathological  conditions  of  the  nasal 
passages,  it  will  be  very  improbable  that  the  teeth  will  remain  in 
correct  occlusion  after  removal  of  the  retaining  device,  regardless 
of  the  time  it  may  have  been  worn,  unless  normal  breathing  be  es- 
tablished so  that  the  mouth  may  be  closed  and  the  teeth  not  de- 
prived of  occlusion  and  the  normal  restraint  and  support  of  the  lips 
the  requisite  amount  of  time.  (See  chapter  on  Normal  Occlusion.) 

Or  if  the  malpositions  of  the  teeth  be  due  to  pathological  con- 
ditions of  the  gums  or  peridental  membrane,  unless  the  condition  be 
changed  by  proper  treatment  permanent  normal  occlusion  cannot 
be.  hoped  for. 

Or  if,  by  the  loss  of  some  one  or  more  teeth,  as  for  example  the 
first  molars,  faulty  occlusion  be  resulting  from  the  tipping  of  the 
remaining  teeth,  the  further  unfavorable  movement  of  these  teeth 
must  be  permanently  arrested  by  crowns  or  bridges,  or  other 
methods  of  replacing  the  missing  teeth  by  artificial  substitutes,  Fig. 
216. 

Again,  if  irregularities  of  the  upper  teeth  have  followed  as  a 
result  of  the  diminished  size  of  the  lower  arch,  from  an  overlapped 
or  irregular  condition  of  the  lower  teeth  (see  Figs.  206  and  208), 


152 


MALOCCLUSION. 


it  would  be  folly  to  expect  the  teeth  of  the  upper  arch  to  be  per- 
manently maintained  in  their  new  positions  unless  occlusion  be  es- 
tablished by  harmonizing  the  proportionate  sizes  of  the  arches  by 
correction  of  the  positions  of  the  lower  teeth. 

Retaining  Devices. — Before  adjusting  the  retaining  devices  it  is 
often  best  to  allow  the  regulating  appliances  to  remain  passively  in 
position  upon  the  teeth  for  a  few  days,  in  order  that  the  tenderness 
of  the  teeth  may  somewhat  subside.  Yet  upon  the  removal  of  the 
regulating  appliances  there  is  usually  found  to  be  more  or  less  sore- 
ness, as  well  as  mobility,  in  the  teeth.  It  is,  therefore,  difficult  or 
impossible  to  form  and  fit  bands  with  any  considerable  degree  of 
accuracy  without  occasioning  pain.  It  is  best  to  adjust  a  temporary 
device  on  exactly  the  same  principles  as  if  it  were  to  be  permanent, 
with  looser  fit  of  bands,  which  may  be  gently  worked  into  position 
with  the  fingers  alone.  If  a  good  quality  of  cement  be  used  the 
device  will  be  firmly  held  in  position  for  a  few  weeks,  until  all 
soreness  will  have  subsided,  when  a  device  with  bands  and  all  other 
parts  of  the  most  perfect  fit  and  finish  may  be  substituted  for  the 
first. 

As  the  retaining  device  is  to  be  worn  for  considerable  time, 
some  authors  prefer  its  construction  from  gold  instead  of  German 
silver,  on  account  of  the  tendency  of  the  latter  to  discolor  in  some 
mouths,  but  it  is  a  fact  which  any  one  may  verify  by  experiment, 
that  bands  of  the  same  delicacy  will  give  far  less  trouble  by  loosen- 
ing if  made  of  German  silver  than  if  made  of  gold,  platinum,  or  of 
any  other  of  the  alloys.  It  may,  however,  be  desirable  in  some  cases 
to  use  spurs  of  platinized  gold. 

The  appliances  necessary  for  retaining  the  teeth  need  never  be 
bulky  nor  complicated,  nor  comprise  a  large  number  of  pieces.  We 
must  remember  that  the  patient  is  doubtless  already  wearied  with 
the  inconvenience  of  the  regulating  appliances,  so  it  should  be  our 
aim  to  make  the  retaining  device  as  delicate,  compact,  and  incon- 
spicuous as  possible,  always,  however,  consistent  with  the  main  ob- 
ject— perfect  support.  The  more  securely  the  teeth  are  held,  the 
more  rapidly  will  they  become  firm  in  their  new  positions.  For 
this  reason,  and  that  it  may  be  as  little  as  possible  under  the  control 
of  the  patient,  the  appliance  should  be  made  stationary  by  the  at- 
tachment of  accurately  fitted  and  cemented  bands  whenever  prac- 
ticable. It  should  also  be  readily  cleansable  by  the  patient,  with  the 


RETENTION.  153 

brush,  that  it  may  in  no  way  injure  the  teeth,  no  matter  how  long 
worn.  It  is  remarkable  how  compact,  simple,  and  yet  efficient,  the 
retaining  devices  may  be  made,  even  for  the  most  complicated  con- 
ditions. 

Principles  of  Retention. — As  the  tendency  of  teeth  that  have 
been  moved  into  occlusion  is  to  return  to  their  former  malpositions, 
the  main  principle  to  be  considered  by  the  designer  of  the  retaining 
device  is  the  antagonizing  of  this  force  in  the  direction  of  its  ten- 
dency only.  Very  slight  antagonism  is  required,  but  its  exercise 
must  be  constant.  If  the  reader  will  keep  this  principle  in  view  he 
will  realize  that  only  delicate  devices  are  necessary,  and  will  be 
impressed  with  the  utter  uselessness  of  much  of  the  bulk  and  ma- 
terial composing  so  many  of  the  retaining  devices  shown  in  our 
literature. 

With  this  in  view,  each  corrected  case  should  be  carefully  studied 
in  connection  with  the  original  models,  noting  the  various  direc- 
tions in  which  the  teeth  are  inclined  to  move,  the  difference  in  their 
sizes,  and  the  proportionate  force  they  will  exert. 

To  secure  retention  we  have  at  our  disposal  support  or  anchorage 
from  the  following  sources :  first,  reciprocal,  or  the  pitting  of  one 
tooth  against  another,  their  tendencies  being  to  move  in  opposite 
or  different  directions ;  second,  teeth  already  firm  in  the  arch ; 
third,  occipital,  as  shown  in  Fig.  97 ;  and  fourth,  and  most  im- 
portant of  all,  the  occlusion  of  the  teeth. 

Application  of  Principles  of  Retention. — The  simple  band  and  the 
short  projecting  wire,  which  for  convenience  we  will  call  a  spur, 
form  the  base  of  a  principle  which  is  applicable  to  nearly  all  the 
requirements  of  retention  in  all  the  various  classes.  It  is  sur- 
prising to  find  in  what  number  of  combinations  the  band  and  spur 
may  be  employed.  If  a  single  tooth  have  been  rotated  into  its  oc- 
clusal  position  it  may  be  prevented  from  returning  to  its  former 
position  (or  antagonized  in  the  direction  of  its  tendency)  by  the 
band  and  spur,  the  spur  being  so  placed  as  to  bear  against  an  ad- 
joining tooth,  as  in  Fig.  142,  the  spur  being  attached  to  the  band 
by  means  of  a  small  tube*  and  key-pin. 

It  is  usually  preferable  to  have  a  band  with  two  spurs,  as  in  Fig. 
143.  These  may  be  soldered  directly  to  the  band.  Unnecessarily 

*Transactions  Ninth  International  Medical  Congress,  September,  1887. 
and  Ohio  Dental  Journal,  October,  1887. 


154 


MALOCCLUSION. 


long  spurs  should  never  be  used,  as  they  are  cumbersome  and 
unsightly.  Even  shorter  spurs  than  those  shown  in  the  engraving 
may  be  employed.  Much  care  should  be  exercised  in  placing  the 
points  which  shall  bear  against  the  adjoining  teeth  so  that  they 
will  not  cause  displacement  of  the  tooth  retained.  If  placed  as 
shown  in  the  engraving,  the  elevation  of  the  lateral  in  its  socket 
would  be  inevitable.  The  point  of  the  spur  should  bear  upon  the 
gingival  ridge  of  the  central,  while  the  point  of  bearing  upon  the 
cuspid  should  be  above  the  swell  of  the  crown.  The  fine  adjust- 


FIG.  142. 


Author's  Retainer. 


ment  of  the  spurs  should  be  left  until  the  cement  has  hardened  after 
setting  the  band,  when  they  may  be  bent  until  their  ends  touch  at 
the  exact  points  required. 

In  some  instances  where  the  period  of  retention  is  to  be  pro- 
tracted, or  where  bands  would  be  unpleasantly  conspicuous,  spurs 
may  be  set  in  fillings,  as  in  Fig.  144,  to  be  drilled  for  the  purpose, 


or  newly  placed  if  any  convenient  cavities  exist.  In  rare  instances 
it  may  even  be  desirable  to  form  minute  cavities  in  the  enamel  to  be 
properly  filled  upon  the  removal  of  the  spur.  In  the  case  of  de- 
ciduous teeth,  soon  to  pass  away,  the  drilling  may  be  considered 
merely  a  matter  of  convenience  and  they  may  often  be  used  in  this 
way  in  preference  to  the  setting  of  bands,  for  short  periods  of  re- 
tention. 

A  method  often  desirable  when  the  space  of  a  lost  tooth  is  to 
be  preserved  is  to  connect  two  bands  by  a  short  section  of  G  wire, 


RETENTION. 


155 


the  ends  being  engaged  in  tubes  R  soldered  to  the  bands,  as  in 

T-  :45- 

Fie,  145. 


E.H.A. 


Another  excellent  modification  of  this  plan  is  shown  in  Fig.  146, 
in  which  one  band  is  dispensed  with,  one  end  of  the  section  of  wire 
G  being  bent  in  the  form  of  a  goose-neck  to  engage  the  mesial 
surface  and  sulcus  of  the  first  bicuspid,  the  other  end  being  sol- 
dered directly  to  a  plain  band  on  the  lateral  incisor. 

FIG.  146. 


£.  H.  A 


If  two  approximating  teeth  have  been  rotated  in  opposite  di- 
rections the  firmest  support  is  given  by  union  of  the  bands  by  solder 
(Guilford).  The  author  now  prefers  uniting  the  bands  by  means 

FIG.  147. 


of  a  spur  soldered  to  the  lingual  surface  of  one  of  the  bands  and 
engaging  a  tube  R  soldered  to  the  lingual  surface  of  the  other  band, 
as  in  Fig.  147.  Or  the  ends  of  the  spur  may  be  united  to  the  lin- 
gual surfaces  of  both  bands  by  solder,  in  which  case  it  becomes 


150  MALOCCLUS1ON. 

two  bands  and  two  spurs  united.  The  spring  of  the  spur  makes 
ease  and  greater  precision  in  the  adjustment  of  the  bands  possible, 
with  less  liability  of  subsequent  loosening. 

The  tendency   to  rotation   of  the  central  and   lateral,   plus   the 
lingual  tendency  of  the  central  and  the  mesial  tendency  of  all,  is 

FIG.  148. 


effectually  resisted  by  two  bands  connected  by  a  spur,  with  an  ad- 
ditional spur  made  to  bear  upon  the  mesio-labial  angle  of  the  lat- 
eral, as  in  Fig.  148.  The  engraving  shows  the  ends  of  the  wire  G 
secured  by  engaging  tubes  soldered  to  the  lingual  surfaces  of  the 
bands.  Direct  attachment  of  the  ends  of  the  wire  to  the  bands  by 
solder  may  of  course  also  be  used,  and  is  often  preferable.  By 
studying  the  tendency  of  the  teeth  it  will  be  seen  how  effectually 
they  are  resisted  by  this  device. 

Fig.  149  shows  where  the  union  of  two  bands  by  a  section  of  G 
wire  is  employed  to  antagonize  the  tendency  of  two  lateral  incisors 

FIG.  149. 


FIG. 


which  have  been  moved  labially  into  the  line  of  occlusion,  while 
another  combination  of  bands  and  spurs,  Fig.  150,  attached  to  the 
centrals  would  accomplish  the  same  result. 


RETENTION.  157 

Another  plan  for  accomplishing  the  same  result  is  by  bands  and 
double  spurs,  as  in  Fig.  151.*  These  consist  of  sections  of  wire  G 
slipped  through  tubes  R  which  have  been  soldered  to  the  labial  sur- 
face of  the  bands  in  anticipation  of  retention,  as  in  Fig.  102,  the 
ends  being  long  enough  to  rest  on  the  labial  surfaces  of  the  ad- 
joining teeth.  The  fit  of  the  tube  should  be  so  perfect  as  to  prevent 
the  loosening  of  the  wire,  but  if  a  dent  be  given  it  on  each  side  of 
the  tube  with  the  regulating  pliers,  it  will  be  effectually  prevented 
from  loosening,  or  a  minute  hole  drilled  through  both  tube  and  side 
of  wire  in  which  is  placed  a  delicate  pin  will  serve  the  same  pur- 
pose (Fig.  142).  If  a  number  of  teeth  require  support  it  may  be 
readily  accomplished  by  the  same  principle  extended  to  include  the 
union  of  two  bands  by  a  spur. 

FIG.  151.  FIG.  152. 


Fig.  152  shows  the  union  of  two  bands  by  a  section  of  G  wire 
which  not  only  accomplishes  the  same  result,  but  would  also  resist 
lateral  pressure  or  rotation  of  one  or  both  of  the  cuspids  if  re- 
quired, while  an  additional  spur  soldered  to  the  long  spur,  as  in 
Fig.  153,  forms  another  combination  for  antagonizing  the  various 
tendencies  of  the  incisors  and  cuspids. 

By  the  addition  of  two  spurs  to  this  combination,  as  in  Fig.  154, 
the  lingual  and  buccal  tendencies  of  the  first  bicuspids  are  also  re- 
sisted in  a  complicated  case  of  malocclusion. 

It  will  be  seen  that  any  or  all  of  the  incisors  and  cuspids  may  be 
firmly  supported  by  combinations  of  the  band  and  spur,  and  that 
the  bicuspids  and  molars  may  be  included  by  extending  the  prin- 
ciple, but  its  greatest  usefulness  is  limited  to  the  incisors  and  cus- 
pids, or  at  most  extended  to  include  the  first  bicuspids,  as  in  Fig. 
154.  If,  however,  a  single  bicuspid  shall  have  been  rotated,  or  if 
a  single  molar  or  bicuspid  shall  have  been  moved  lingually  or  buc- 
cally,  the  band  and  double  spur  made  to  bear  against  the  adjoin- 
ing teeth,  the  same  as  already  described  for  retention  of  an  incisor, 
will  be  most  efficient. 

*Transactions  Ninth  International  Medical  Congress,  September,  1887. 


158 


MALOCCLUSION. 


For  the  retention  of  cuspids  that  have  been  retracted  of  course 
nothing  could  be  more  efficient  than  to  allow  the  traction  screws  to 
remain  in  position  as  retainers,  which  should  usually  be  done  for  at 
least  two  months.  This  is  only  another  form  of  the  principle  of 

FIG.  153. 


FIG.  154. 


two  bands  and  spurs  united.  As  the  device  is  more  bulky  than 
is  necessary,  it  may  be  removed  after  the  time  stated,  and  what  is 
now  the  author's  favorite  plan  for  protracted  retention  of  these 
teeth  be  employed.  A  delicate  plain  band  is  made  to  encircle  the 
bicuspid,  having  two  tubes  R  soldered,  one  to  the  mesio-lingual 
and  one  to  the  mesio-labial  angles  of  the  band  close  to  the  gum. 


RETENTION. 


159 


Ends  of  a  section  of  the  ligature  wire  are  passed  through  these 
tubes  and  the  wire  drawn  tightly  against  the  mesial  surface  of 
the  cuspid.  The  ends  are  then  bent  sharply  around  and  clipped 
off.  Twisting  is  unnecessary.  All  is  correctly  shown  in  the  en- 
graving, Fig.  155. 

FIG.  155. 


By  means  of  this  device  ample  support  is  gained  and  the  bulk 
and  conspicuousness  reduced  to  the  minimum.  It  is  important  that 
the  tubes  shall  be  close  to  the  gum,  so  the  mesial  end  of  the  wire 
loop  cannot  slide  off  the  cuspid  crown. 


FIG.  156. 


FIG.  157. 


Retention  of  a  number  of  teeth  may  be  effected  by  a  union  of 
bands  encircling  them,  as  in  Figs.  156  and  157.  This  method, 
however,  is  not  advisable,  as  much  unnecessary  space  between  the 
teeth  is  thus  monopolized,  while  it  is  impossible  to  hold  all  so 
rigidly  together  but  that  one  or  more  will  become  uncemented. 

In  the  use  of  all  bands  in  retention  we  would  caution  that  thev 


l6o  MALOCCLUSION. 

be  inspected  at  least  once  in  two  months,  for  if  they  should  be- 
come loosened  they  would  act  as  receptacles  for  food  particles,  the 
fermentation  of  which  might  injure  the  enamel. 

The  retention  of  molars  and  bicuspids  is  usually  confined  to 
resisting  their  lingual  tendency  after  the  arch  has  been  widened  by 
the  buccal  movement  of  one  or  both  of  its  lateral  halves.  A  neatly 
fitting  vulcanite  or  metal  plate,  as  in  Fig.  158,  partially  covering 
the  palatine  arch  and  bearing  against  the  teeth  that  have  been 
moved,  is,  in  the  author's  opinion,  by  far  the  most  simple  and 
practicable  device  for  the  purpose  yet  produced.  This  device  has 
been  employed  for  this  purpose  for  many  years,  and  would  probably 
suggest  itself  to  any  artificial  plate-maker.  Its  origin  is  lost  in 

obscurity. 

FIG.  158. 


In  order  to  gain  the  greatest  accuracy  of  fit  this  little  plate 
should  always  be  constructed  over  a  plaster  impression,  only  enough 
plaster  being  used  to  take  the  imprints  of  the  surfaces  needed.  The 
plate  should  not,  during  the  early  stage  of  retention,  extend  far 
enough  forward  to  rest  in  contact  \vith  the  incisors  or  cuspids,  for 
owing  to  their  sloping  surfaces  the  plate  is  wholly  unreliable  for 
their  support  and  would  only  interfere  with  other  appliances,  be- 
sides being  superfluous  bulk.  It  may  be  necessary  to  secure  the 
plate  in  position  in  some  instances,  which  may  be  done  by  springing 
each  lateral  edge  under  a  lug  soldered  to  a  band  encircling  a  tooth. 
Such  bands  may  usually  be  dispensed  with  after  a  short  time,  when 
the  plate  has  become  better  settled  in  position  and  the  force  exerted 
by  the  teeth  has  become  less  marked. 

During  the  last  stage  of  retention,  or  when  the  tendency  to 
resumption  of  malpositions  shall  have  nearly  subsided,  the  bands 
and  spurs  upon  the  incisors  may  be  removed  and  a  plate  extending 
forward  and  made  to  accurately  fit  their  lingual  surfaces  may  be 


RETENTION.  l6l 

used,  as  in  Fig.  159.  In  this  engraving  is  shown  how  a  portion  of 
the  side  of  a  stay  plate  has  been  removed  and  a  piece  of  the  wire 
G  bent  in  such  a  way  as  to  bear  upon  the  teeth,  the  ends  of  the  wire 
engaging  cavities  in  the  plate.  By  this  means  pressure,  if  desira- 
ble, may  be  brought  to  bear  upon  the  teeth  by  occasionally  remov- 
ing the  staple  and  pinching  it  with  the  regulating  pliers. 

A  similar  plate  may  be  used  for  resisting  the  lingual  tendency 

FIG.  159. 


of  the  inferior  bicuspids  and  molars.  If  plates  be  required  for 
both  arches  the  upper  one  may  be  dispensed  with  a  considerable 
time  before  the  lower,  provided  the  proper  occlusion  shall  have 
been  established,  as  the  occlusion  will  then  be  sufficient  to  support 
the  upper  teeth.  Where  labial  protrusion  of  the  incisors  shall  have 
been  reduced,  as  in  Class  II,  Division  i,  it  must  be  remembered 
that  their  tendency  is  not  only  to  move  outward  but  also  downward 

FIG.  160. 


in  most  cases,  so  it  is  difficult  to  secure  them  by  any  device  having 
for  its  anchorage  the  remaining  teeth  in  the  arch  without  their 
lengthening  more  or  less  or  the  anchor  teeth  being  gradually  drawn 
forward. 

The  little  device  shown  in  Fig.  160,  if  intelligently  managed, 
fully  meets  the  requirements.  It  consists  of  a  delicate  vulcanite 
plate  covering  the  labial  surfaces  of  the  incisors,  as  well  as  their 
cutting-edges,  and  about  one-fourth  of  their  lingual  surfaces.  It 


1 62 


MALOCCLUSION. 


is  also  often  well  to  let  the  plate  extend  to  bear  against  the  mesio- 
labial  surface  of  the  cuspids.  It  is  used  in  connection  with  the 
head-gear  and  traction  bar,  having  a  spur  imbedded  in  the  center 
to  engage  the  standard  on  the  traction  bar,  and  is  worn  only  during 
the  night,  with  much  lighter  elastics  than  were  employed  in  the 
retraction  of  the  teeth,  or  only  sufficient  to  give  the  teeth  gentle 

support. 

FIG.  161. 


A  similar  device,  but  of  skeleton  form,  made  from  metal,  shown 
in  Fig.  161,  may  also  be  used,  although  it  is  less  satisfactory.  It 
consists  of  a  segment  of  the  arch  B  to  which  two  short  pieces  of 
the  wire  G  have  been  soldered  at  right  angles,  at  points  opposite 
the  centers  of  the  central  incisors.  They  are  long  enough  so  that 
the  ends  may  be  flattened  and  bent  over  the  cutting-edges  of  the 
centrals,  the  hooks  so  formed  preventing  the  appliance  from  sliding 

FIG.  162. 


upward  against  the  gum.  The  device  is  prevented  from  sliding 
laterally  by  a  spur  soldered  to  the  segment,  the  end  resting  in  the 
depression  between  the  centrals. 

To  compel  the  jaw  to  close  forward  so  that  the  teeth  of  the  entire 
arch  will  be  shifted  from  distal  to  normal  occlusion,  as  in  one  plan 
of  treating  cases  belonging  to  the  first  division  of  Class  II,  the 
device  shown  upon  the  molars  in  Fig.  162  is  very  satisfactory.  No.  2 


RETENTION. 


163 


clamp  bands  are  firmly  clamped  and  cemented  upon  the  first  molars 
on  one  side.  Upon  the  buccal  surface  of  the  lower  band  has  been 
soldered  a  strong  spur,  which  is  bent  upward  in  order  to  close  in 
front  of  a  strong  plane  of  metal  which  has  been  firmly  soldered  to 
the  buccal  surface  of  the  band  upon  the  upper  molar.  This  piece 
of  metal  should  be  about  one-fourth  of  an  inch  in  width  and  three- 
eighths  of  an  inch  in  length,  and  should  extend  outward  at  right 
angles  to  the  long  axis  of  the  tooth,  so  that  the  jaw  when  closing 
must  be  brought  forward  to  the  point  required  for  normal  occlu- 
sion. The  spur  should  be  of  sufficient  length  to  extend  at  least 
one-fourth  of  an  inch  above  the  plane  of  metal  when  the  jaws  are 
closed.  The  positions  are  well  shown  in  the  engraving. 

FIG.  163. 


Another  device  for  accomplishing  the  same  result  is  shown  in 
Fig.  163.  D  bands  are  placed  upon  the  first  molars  on  one  side,  the 
tubes  on  the  bands  having  been  reduced  to  about  one-fourth  inch 
in  length.  Into  these  tubes  are  sprung  two  engaged  open  links, 
made  from  one  of  the  heavy  levers  L  or  of  hard  German  silver 
wire.  It  renders  all  distal  movement  of  the  jaw  impossible,  while 
permitting  free  lateral  movement  by  the  turning  of  the  links  in  the 
tubes.  It  also  admits  the  separation  of  the  jaws  the  full  normal 
distance  by  the  sliding  of  the  links  upon  each  other,  at  the  same 
time  offering  no  resistance  to  the  desired  forward  extension  of 
the  jaw. 

This  device  is  the  author's  modification  of  one  made  by  Dr. 
McDowell,  which  consisted  of  a  long  upright  link  soldered  rigidly 


164  MALOCCLUSION. 

to  the  lower  band  and  engaging  a  staple  soldered  to  the  upper  band 
at  right  angles,  the  model  of  which  is  in  the  author's  possession. 
This  device  did  not  permit  any  considerable  opening  of  the  jaws,  as 
sufficient  length  of  link  interfered  with  the  buccinator  muscle,  and 
it  prevented  all  lateral  movement. 

The  author  has  not  tested  this  device  in  a  sufficient  number  of 
cases  to  be  certain  of  its  complete  practicability.  While  it  possesses 
the  requisites  for  compelling  normal  closure  of  the  jaw,  yet  it  may 
be  found  to  require  more  attention  than  that  of  simpler  construc- 
tion, in  Fig.  162. 

Another  device  for  compelling  normal  position  of  the  jaw  when 
closed  in  these  cases,  and  also  for  resisting  the  labial  and  lengthen- 
ing movements  of  the  upper  incisors,  is  shown  in  Fig.  164.  A  cap 

FIG.  164. 


of  metal  is  swaged  to  accurately  fit  and  cover  collectively  the 
crowns  of  the  lower  incisors.  Soldered  to  its  labial  surface  is  a 
square  bar  of  metal  one-sixteenth  inch  in  diameter,  on  a  line  with 
and  corresponding  to  the  occlusal  surfaces  of  the  upper  incisors. 
To  the  labial  surface  of  this  bar  are  soldered  small  spurs  which  pro- 
ject upward  about  one-eighth  of  an  inch  and  bear  against  the  middle 
of  the  labial  surfaces  of  the  upper  central  incisors  when  the  jaws 
are  closed,  as  shown  in  the  engraving. 

A  better  modification  of  this  principle  is  to  place  upon  the  lower 
central  incisors  plain  bands,  having  soldered  to  their  labial  surfaces 
strong  spurs,  which  project  forward  and  are  bent  upward  sharply 
at  right  angles  to  engage  the  labio-occlusal  edges  of  the  upper 
incisors.  The  stability  of  the  teeth  used  as  anchorage  should  be 
reinforced  by  a  section  of  the  G  wire  soldered  across  the  lingual 
surface  of  their  bands  and  made  to  bear  against  the  adjoining 
lateral  incisors. 

Sometimes  it  may  be  desirable  to  place  the  bands  upon  the  cus- 


RETENTION. 


pids,  instead  of  upon  the  incisors,  and  connect  them,  as  shown  in 
Fig.  164,  by  a  bar  of  metal  containing  the  retaining  spurs. 

If  the  reader  will  study  this  device  he  will  observe  that  not  only 
is  normal  closure  of  the  jaw  compulsory,  but  that  the  incisors  are 
kept  compressed  in  their  sockets  and  prevented  from  moving  la- 
bially,  as  well.  Still  another  advantage  of  no  small  importance  is 
gained  in  preventing  the  lower  lip  from  being  drawn  against  the 
lingual  surfaces  of  the  upper  incisors,  a  habit  which  seems  to  be 
almost  universal  in  these  cases,  and  difficult  but  most  necessary  to 
overcome. 

Figs.  165  and  166  show  Dr.  Baker's  method  of  retention,  by  what 
he  terms  "hygienic  retaining  plates,"  referred  to  in  Chapter  XIX. 


FIG.  165. 


FIG.  166. 


The  upper  one  consists  of  a  vulcanite  plate  limited  to  cover  only 
a  sufficient  portion  of  the  palatine  arch  to  give  it  proper  support 
by  suction.  For  the  support  of  the  bicuspids  and  molars  flattened 
wire  projections  radiate  from  the  plate  and  bear  against  their  lin- 
gual surfaces.  The  metal  may  be  of  German  silver  or  platinous 
gold.  To  insure  their  being  kept  in  the  proper  position  during  the 
packing  and  vulcanizing  of  the  rubber  the  wires  should  be  sharpened 
at  their  palatine  ends,  bent  sharply  at  right  angles, and  made  to  pene- 
trate the  plaster  model  to  a  depth  of  one-eighth  of  an  inch  or  more  at 
points  corresponding  with  the  margin  of  the  air  chamber.  After 
the  plate  has  been  vulcanized  these  imbedded  palatine  projections 
are  clipped  off  even  with  the  palatine  surface  of  the  plate. 

An  advantage,  in  addition  to  the  cleanliness  of  such  a  plate, 
is  that  the  projections  may  be  lengthened  by  beating  or  by  means 


1 66  MALOCGLUSION. 

of  the  regulating  pliers,  or  they  may  be  shortened,  or  bent  to  exert 
slight  pressure  upon  the  mesial  or  distal  angles  of  the  teeth,  for  the 
finer  adjustment  of  the  positions  of  the  teeth. 

To  resist  the  labial  movement  of  the  incisors  a  loop  of  wire  is 
made  to  bear  against  their  labial  surfaces,  the  ends  passing  be- 
tween the  lateral  incisors  and  cuspids  and  imbedded  in  the  plate. 
This  latter  attachment,  however,  was  original  with  Dr.  N.  W. 
Kingsley.* 

The  same  general  plan  is  followed  in  the  construction  of  the 
lower  plate.  In  addition  to  projections  for  the  support  of  the 
teeth,  hook-like  projections  are  made  to  engage  the  lingual  grooves 
of  the  molars  to  prevent  the  plate  from  working  down  upon  the 
gums.  To  prevent  elevation  of  the  anterior  part  of  the  plate,  pro- 
jections are  sprung  under  bands  cemented  upon  the  first  bicuspids. 


CHAPTER    XIII. 

TISSUE    CHANGES    INCIDENT    TO    TOOTH    MOVEMENT. 

IN  adjusting  malposed  teeth  into  harmony  with  the  normal  line 
of  occlusion  there  are  seven  distinct  movements  possible:  first, 
labially  or  buccally ;  second,  lingually ;  third,  mesially ;  fourth,  dis- 
tally ;  fifth,  elevation  ;  sixth,  depression  ;  seventh,  rotation.  These 
can  only  be  accomplished  in  accordance  with  the  physiological  laws 
which  govern  the  changes  possible  in  the  alveolus  and  peridental 
membrane.  The  peculiarities  of  the  tissues  involved  and  the  rich- 
ness of  their  vascular  supply  admit  of  much  disturbance  of  these 
tissues  with  a  very  reasonable  assurance  of  nature's  complete 
restoration,  provided  these  movements  be  properly  conducted. 

While  the  movement  of  a  single  tooth  only  is  frequently  neces- 
sary, as  the  movement  labially,  or  rotation  of  an  incisor,  more  often 
it  is  necessary  to  combine  two,  three,  or  even  four  movements, 
as  for  example,  a  prominent  cuspid  may  require  elevation,  rotation, 
lingual,  and  possibly  distal  movements,  all  of  which  may  be  accom- 
plished at  the  same  time  with  a  suitable  appliance.  But,  as  there 

*Kingsley's  "Oral  Deformities." 


TISSUE    CHANGES    INCIDENT    TO    TOOTH    MOVEMENT.  167 

is  so  much  disturbance  of  the  tissues  involved  in  so  great  a  change 
in  the  position  of  the  tooth,  more  time  should  be  employed  than  in 
a  single  movement. 

Again,  the  movement  of  a  number  of  teeth,  and  in  various  direc- 
tions, not  only  in  one  arch  but  both,  may  often  be  necessary  and  may 
be  accomplished  simultaneously. 

When  force  is  exerted  upon  the  teeth  to  be  moved,  two  principal 
changes  take  place  in  the  alveolus.  First,  a  bending  of  the  process ; 
second,  absorption  of  the  process  in  advance  of  the  moving  tooth 
and  deposition  of  bone  behind  it.  These  changes  vary  greatly — 
according  to  the  age  of  the  patient,  in  different  patients  of  the  same 
age,  in  the  direction  of  movement,  and  also  in  the  rapidity  of  move- 
ment. 

In  youth,  or  before  the  bone  has  become  dense  by  a  preponderance 
of  inorganic  substance,  it  permits  of  much  bending,  so  that  incisors 
may  be  moved  out  of  inlock  in  a  few  hours,  or  the  lateral  halves  of 
the  arch  widened  in  a  very  few  days,  OF-  before  much  absorption 
could  have  taken  place  in  advance  of  the  moving  tooth.  In  further 
proof  of  this  the  process  will  be  found  upon  examination  to  be  intact 
about  the  roots,  not  only  on  the  labial  side,  or  in  front  of  the  mov- 
ing tooth,  but  on  the  lingual,  or  opposite  side,  as  well,  it  having  been 
dragged  after  the  moving  tooth.  This  is  easily  explained  when  we 
remember  the  cancellous  structure  of  the  bone,  the  inelasticity  of  the 
fibers  of  the  peridental  membrane,  and  their  very  strong  attach- 
ment to  it. 

Another  striking  illustration  of  the  bending  of  the  bone  occa- 
sioned by  the  strong  attachment  is  in  the  distal  movement  of  the 
cuspid  into  the  space  made  vacant  by  the  removal  of  the  first  bi- 
cuspid. The  author  has  frequently  noted  that  not  only  the  septum 
of  bone  just  mesial  to  the  cuspid  closely  follows  the  moving  tooth, 
but  in  some  instances  even  the  lateral  incisor  is  dragged  in  the 
same  direction  to  quite  an  extent,  owing  probably  in  the  main  to 
the  strength  of  the  fibers  composing  the  dental  ligament. 

While  more  or  less  springing  of  the  bone  is  probably  always  an 
accompaniment  of  tooth  movement,  yet  in  proportion  as  the  bone 
becomes  dense  with  age  so  the  modification  of  the  process  attend- 
ant upon  tooth  movement  changes  from  springing  to  the  slower 
action  of  absorption  and  the  still  more  slow  deposition  of  bone. 

Coincident  with  the  changes  in  the  bone  there  are  also  pronounced 


l68  MALOCCLL'iSION. 

changes  taking  place  in  the  peridental  membrane.  As  force  is 
exerted  on  the  moving  tooth  the  membrane  is  compressed  in  front 
of  it,  between  it  and  the  alveolus,  while  a  greater  tension  of  the 
fibers  of  the  membrane  takes  place  on  the  opposite  side.  As  a  result 
of  this  tension  and  compression  the  nerves  of  the  membrane  are 
impinged  upon,  causing  a  greater  or  less  sense  of  pain,  which,  as  a 
result  of  the  slight  movement  of  the  tooth  and  temporary  paralysis 
of  the  nerves  from  pressure,  subsides  more  or  less  quickly,  accord- 
ing to  the  amount  of  inflammation  present. 

As  a  result  of  this  pressure  the  absorbent  cells,  or  osteoclasts, 
are  stimulated  to  increase  in  number  and  activity.  They  immedi- 
ately engage  in  the  absorption  of  the  portion  of  bone  most  involved 
in  the  movement,  as  well  as  of  the  bone  attachments  of  the  fibers  on 
greatest  tension. 

.  While  these  changes  are  taking  place,  the  osteoblasts  have  become 
active  and  have  begun  filling  up  the  depression  and  re-attaching 
the  fibers  by  the  redeposition  of  bone;  but  as  this  is  a  much 
slower  process  than  that  of  absorption  the  tooth  is  found  to  be  more 
or  less  loose  in  its  socket  at  the  completion  of  its  movement,  as 
well  as  long  after,  necessitating  its  being  supported  by  means  of 
the  retaining  devices  until  the  deposition  of  bone  shall  be  complete 
and  a  perfect  socket  reformed  for  its  support  in  its  new  position. 

If  a  tooth  be  elevated  in  its  socket  the  principal  change  involves 
the  peridental  membrane.  The  fibers  at  the  end  directly  resisting 
this  movement  are  severed,  and  the  oblique  or  suspensory  fibers  are 
stretched  and  recurved  upon  themselves.  The  result  of  the  partial 
withdrawal  of  the  conical  root  is  increased  space,  not  only  at  the 
end  but  also  on  the  sides  of  the  root,  so  that  there  is  considerable 
freedom  of  movement  of  the  tooth,  necessitating  the  deposition  of 
bone  over  the  entire  surface  of  its  socket,  as  well  as  increase  of 
height  of  margin. 

In  the  movement  of  depression  the  bone  must  be  absorbed  by  the 
osteoclasts  over  the  entire  surface  of  the  alveolus  to  allow  for  the 
advance  of  the  root  of  conical  form.  The  fibers  of  lateral  support 
are  stretched  and  placed  on  different  angles,  while  the  suspensory 
fibers  are  also  stretched  and  severed  at  their  points  of  attachment  to 
the  bone,  thereby  necessitating  more  disturbance  of  tissues  and  re- 
quiring more  force  and  time  than  any  other  of  the  seven  move- 
ments. 


TISSUE    CHANGES    INCIDENT    TO    TOOTH    MOVEMENT.  169 

In  the  rotating  of  a  tooth  in  its  socket  little  change  by  springing 
or  bending  is  probable,  the  principal  change  being  absorption  of 
the  fibers  and  bone  involved  along  the  entire  length  of  the  root. 

In  all  cases  of  tooth  movement  a  large  number  of  the  fibers  of 
the  membrane  remain  on  tension  long  after  the  movement  is  com- 
plete, the  force  they  exert  tending  to  draw  the  tooth  back  to  its 
original  position,  thus  necessitating  considerable  support  from  the 
retaining  devices  until  the  tissues  have  become  thoroughly  re- 
established in  harmony  with  the  tooth  in  its  new  position. 

In  accomplishing  the  movement  of  teeth  lingually,  labially  (or 
buccally),  mesially,  or  distally,  the  principal  change  is  in  the 
position  of  the  crown  of  the  tooth,  it  being  tipped  into  its  correct 
position.  The  usual  supposition  is  that  the  tooth  in  the  alveolus 
acts  as  a  lever,  the  crown,  or  long  end  of  the  lever,  moving  in  5ne 
direction,  the  apex  of  the  root  in  the  opposite  direction.  To  make 
clear  these  supposed  changes,  and  especially  the  extent  of  the  move- 
ment of  the  apex,  writers  have  frequently  used  the  illustration  of 
a  post  driven  into  the  earth  about  one-third  of  its  length.  If 
force  be  exerted  at  right  angles  to  a  side  of  the  post  near  its  top 
the  post  will  act  as  a  lever  in  the  displacement  of  the  soil,  the 
two  ends  of  the  lever  moving  in  opposite  directions  and  the  pivotal 
point  being  somewhere  near  the  beginning  of  the  last  third  of  the 
imbedded  portion. 

The  illustration  is  a  poor  one  and  very  misleading,  as  the  me- 
chanical conditions  are  very  different.  Doubtless  this  would  be 
the  result  if  the  tooth,  like  the  post,  had  but  one  resistant  substance 
and  that  equally  distributed  in  all  directions  about  its  root,  but  as  we 
have  already  seen  in  the  study  of  the  alveolus,  the  bone  varies  greatly 
in  thickness  over  different  portions  of  the  root  and  in  different  teeth, 
so  the  amount  of  displacement  of  the  apex  of  the  root  of  a  tooth  de- 
pends, ofttimes,  upon  the  location  and  movement  of  the  tooth  and 
whether  one  tooth  or  a  number  in  the  same  region  are  being  moved 
in  the  same  direction.  In  reality  there  may  be  little  or  no  displace- 
ment of  the  apex,  or  there  may  be  considerable. 

In  the  first  place,  the  alveolus  is  not  a  level  plane,  like  that  in 
which  the  post  is  implanted,  but  a  projection  or  high  ridge,  of  elastic 
structure,  and  admits  of  some  bending  laterally,  its  susceptibility  to 
this  action  increasing  proportionately  as  we  approach  .the  top.  It 
would  be  especially  favorable  in  the  labial  movement  of  the  incisors, 


I/O  MALOCCLUSION. 

as  in  Fig.  167.     The  pronounced  bending  of  the  process  is  a  matter 
of  common  observation  in  efforts  at  extraction. 

Again,  the  mechanical  difference  in  the  attachment  of  the  post 
to  the  soil  and  the  tooth  to  the  alveolus  is  such  as  to  still  further 
add  greatly  to  the  difference  in  the  results  of  their  movements. 
As  the  apex  of  the  root  is  implanted  deep  in  the  bone,  which  is 
greatly  thickened  in  its  lingual  direction  and  reinforced  by  the 
strong  cortical  layer  of  the  alveolus,  its  movement  lingually  could 
not  well  take  place  as  a  result  of  springing.  This  movement  is 
further  strongly  resisted  by  the  innumerable  inelastic  fibers  that 
encapsule  the  apex,  radiating  in  all  directions  for  its  firmest  possible 
attachment  to  the  bone,  their  ends  being  inclosed  in  its  structure. 

FIG.  167. 


So  in  the  labial  movement  of  the  crown  the  lingual  movement  of 
the  apex  of  the  root  is  not  only  resisted  by  the  bone  in  front,  but  also 
behind  and  on  each  side,  by  reason  of  its  attachment,  while  with  the 
end  of  the  post  little,  if  any,  resistance  is  offered  by  the  soil  behind 
or  on  either  side,  but  only  by  that  in  front. 

Another  difference.  The  force  for  the  movement  of  the  post  is 
applied  remote  from  the  fulcrum,  while  the  force  exerted  on:  the 
tooth  by  the  ligature  is  applied  close  to  the  fulcrum,  or  at  a  point 
best  calculated  to  facilitate  the  bending  of  the  alveolus  in  the  labial 
direction. 

Again,  unlike  the  single  post,  several  teeth  may  be  associated  in 
the  movement,  which  adds  still  further  to  the  possibilities  of  the 
labial,  as  well  as  adding  correspondingly  to  the  impossibilities  of  the 
lingual,  movement  of  their  apices. 


TISSUE    CHANGES    INCIDENT    TO    TOOTH    MOVEMENT.  I/I 

In  the  lingual  movement  of  incisors  there  is  often  considerable 
labial  movement  of  the  apices  of  the  roots,  owing  to  the  lesser  re- 
sistance offered  by  their  thin  covering  of  bone  and  the  much  greater 
thickness  of  bone  on  the  lingual  surfaces  of  the  roots.  The  result 
is  often  noticed  following  the  reduction  of  protruding  incisors,  as 
in  those  cases  belonging  to  Division  I  of  Class  II. 

In  the  similar  movements  of  the  upper  cuspids  and  bicuspids, 
practically  the  same  changes  in  the  positions  of  the  roots  follow. 

In  the  movement  buccally  of  the  upper  molars  there  is  bending 
or  absorption  of  the  outer  plate,  the  palatine  roots  are  elevated  in 
their  sockets  to  make  easier  the  tipping  of  the  crown,  with  probably 
no  movement  at  the  apices  of  the  buccal  roots,  unless  it  be  that 
they  are  forced  deeper  in  their  sockets.  In  the  lingual  movement 
of  the  same  teeth  there  is  more  or  less  bending  of  the  process,  the 
forcing  deeper  in  its  socket  of  the  palatine  root,  with  perhaps  some 
elevation  in  their  sockets  of  the  buccal  roots. 

FIG.  168. 


In  the  same  movements  of  the  lower  molars  there  is  greater  dis- 
placement of  the  apices  of  the  roots  in  the  opposite  direction  from 
which  the  crowns  are  moved,  owing  to  the  great  thickness  of  the 
buccal  plate  of  the  alveolus. 

In  the  movement  of  teeth  mesially  or  distally  there  can  be  little 
or  no  bending  of  the  labial  and  lingual  plates,  the  chief  resistance 
now  being  offered  by  the  septse  and  the  peridental  attachments, 
and  the  movement  of  the  teeth  more  nearly  resembles  the  move- 
ment of  the  post,  the  apex  moving  slightly  in  the  opposite  direc- 
tion from  the  crown,  as  in  Fig.  168.  And  yet  the  displacement 
of  the  apex  in  these  movements  may  be  considerably  diminished  by 
proper  surgical  operations  on  the  tissues,  of  which  we  shall  speak  in 
the  next  chapter. 

While  the  pulp  of  the  tooth  is  a  tissue  more  or  less  involved  in 
tooth  movement,  yet  when  the  operation  is  properly  performed  this 


1/2  MALOCCLUSION. 

tissue  is  practically  undisturbed  and  should  suffer  no  real  injury. 
On  the  other  hand,  its  normal  function  may  be  so  interfered  with  as 
to  cause  it  to  suffer  marked  disturbance  and  even  complete  devitali- 
zation, especially  if  the  movement  be  conducted  too  rapidly  or  the 
force  be  applied  too  abruptly.  The  principal  danger,  however,  arises 
from  congestion  and  inflammation  of  the  tissues  of  the  apical  space, 
causing  the  partial  or  complete  strangulation  of  the  vascular  supply 
to  the  pulp.  In  view  of  these  facts  it  should  be  our  aim  to  prevent, 
as  far  as  possible,  all  tendency  toward  inflammation.  If  the  pulp 
becomes  partially  congested,  as  is  usually  evinced  by  a  slight  change 
in  color,  as  shown  through  the  enamel,  and  by  sensitiveness  to 
thermal  changes,  the  tooth  should  be  allowed  to  remain  passive  for 
several  days,  when,  usually,  these  symptoms  will  subside.  The 
author  has  noticed  several  instances  where  these  symptoms  have 
been  markedly  manifest  and  have  wholly  subsided  under  palliative 
treatment.  Sometimes,  however,  complete  devitalization  will  fol- 
low, and  while  the  death  of  the  pulp  under  these  conditions  is  to  be 
regretted,  yet  the  consequences  are  not  of  sufficient  importance  to 
occasion  any  more  regret  than  when  found  necessary  in  the  treat- 
ment of  teeth  for  caries.  The  principal  evil  following  the  death 
of  the  pulp  in  these  cases  is  the  possible  permanent  discoloration  of 
the  crown,  which  is  more  liable  to  follow  the  speedy  death  from 
strangulation  than  the  slow  devitalization  from  the  encroachment 
of  caries.  For  this  reason,  whenever  complete  devitalization  of 
the  pulp  shall  be  apparent  it  should  be  immediately  removed  and 
the  canal  repeatedly  washed  out  with  tepid  water,  sterilized  and 
carefully  filled  in  the  usual  way,  when  the  further  movement  of  the 
tooth  may  be  conducted  without  greater  fear  of  inflammation  than 
if  the  pulp  were  intact.  In  like  manner,  if  it  be  desirable  to  change 
the  position  of  a  tooth  having  an  already  devitalized  pulp  it  may 
be  resorted  to  without  hesitancy,  provided  the  surrounding  tissues 
be  healthy  and  the  pulp-canal  be  first  properly  cleansed  and  filled. 
It  is  often  desirable  to  perform  tooth  movement  soon  after  the 
eruption  of  the  teeth,  or  at  a  time  before  the  root  is  fully  formed, 
the  end  of  the  root  then  having  a  broad,  funnel-shaped  opening.  If 
the  movement  be  intelligently  performed  the  pulp  at  this  age  should 
suffer  no  greater  disturbance  than  when  the  root  is  fully  calcified. 
In  fact,  there  is  less  probability  of  strangulation  and  death  than 
later  when  the  foramen  is  greatly  diminished  in  size. 


OPERATIVE    SURGERY.  173 


CHAPTER    XIV. 

OPERATIVE    SURGERY. 

WHILE  all  tooth  movement  is  essentially  surgical,  that  by  the 
use  of  appliances  may  be  properly  called  Conservative  Surgery. 
To  distinguish  the  more  bold  or  aggressive  operations  involving 
the  use  of  cutting  instruments  we  will  designate  them  as  Operative 
Surgery.  While  such  operations  should  probably  be  employed  only 
as  auxiliary  to  the  conservative  method,  they  are  doubtless  destined 
to  play  a  more  important  part  in  the  practice  of  the  future,  and  will 
be  briefly  considered. 

Immediate  Movement. — As  the  changes  in  the  tissues  incident  to 
tooth  movement  are  as  a  rule  necessarily  slow,  requiring  that  the 
operation  shall  be  more  or  less  protracted,  different  writers*  from 
time  to  time,  among  whom  may  be  mentioned  Tomes,  Stellwagen, 
and  Bryan,  have  advocated  that  sufficient  force  be  exerted  by  suit- 
able forceps  to  effect  the  immediate  movement  of  teeth  into  cor- 
rect positions. 

Dr.  Bryan,  of  Basle,  Switzerland,  was  first  to  improve  on  the 
operation  by  surgically  removing,  with  suitable  instruments,  a  por- 
tion of  bone  in  advance  of  the  moving  tooth,  t 

The  immediate  movement  of  teeth  has  usually  been  resorted  to 
only  where  one,  or  at  most  two,  teeth  were  to  be  rotated  or  moved 
from  inlock.  The  operation  has  never  met  with  much  favor  and 

*J.  Lefoulon,  who  wrote  a  work  in  1841  (French),  which  was  trans- 
lated and  published  in  the  American  Library  of  Dental  Science,  says  on  pages 
132  and  133,  "Almost  all  the  writers  who  have  treated  on  this  subject,  i.e., 
regulating,  have  spoken  of  artificial  luxation.  This  is  a  means  which  we 
have  already  condemned,  and  which  we  cannot  too  frequently  disapprove. 
The  ancients,  and  some  of  the  moderns,  yet  imitate  them,  employing  the 
'pelican'  for  this  purpose;  a  violent  maneuver,  which  exposed  them  to  the 
risk  of  breaking  the  tooth  at  the  neck,  and  thus  to  replace  a  deformity  by  a 
mutilation  a  hundred  times  worse.  Besides  it  is  a  cruel  operation,  which 
should  be  rejected  the  instant  mild  means  can  be  employed  which,  at  least, 
are  equally  efficacious." 

tDescribed  in  a  paper  read  before  the  American  Dental  Society  of  Europe 
in  August,  1892. 


1/4  MALOCCLUSION. 

doubtless  never  will,  for  it  is  a  practice  as  inexcusable  and  imprac- 
ticable as  it  is  barbarous. 

First,  it  is  so  formidable  that  naturally  but  few  would  care  to 
submit  to  it. 

Second,  the  risk  to  the  tooth  and  pulp,  as  well  as  to  the  other 
tissues  involved,  is  so  great  that  it  is  wholly  unwarrantable. 

Third,  as  the  malposition  of  one  tooth  is  nearly  always  but  a 
marked  symptom  of  a  more  general  malocclusion,  often  involving 
several  teeth  in  the  same  arch,  as  well  as  in  the  opposite,  so  that 
its  proper  placement  must  necessitate  the  enlargement  of  the  dental 
arches  and  the  correction  of  the  positions  of  the  other  teeth,  espe- 
cially of  those  on  either  side  of  it,  the  immediate  movement  is 
utterly  ineffectual. 

And  last,  it  is  wholly  unnecessary,  as  in  such  cases  as  would 
seem  most  favorable  for  this  operation  a  suitable  appliance  will 
in  a  very  short  time  effect  by  the  conservative  method  the  desired 
result,  without  risk  and  with  but  little  more  than  inconvenience  to 
the  patient. 

Alveolar  Section. — The  removal  of  bone  in  advance  of  the  mov- 
ing tooth,  if  properly  performed,  may,  we  think,  be  desirable  in 
many  cases  if  connected  with  the  conservative  method.  The  author 
has  in  a  large  number  of  cases  found  it  expedient.  While  it  is 
probably  never  indicated  in  the  movement  of  teeth  of  young  chil- 
dren, in  patients  of  more  advanced  age,  where  the  bone  is  dense  and 
of  considerable  thickness  and  absorption  slow,  it  may  be  resorted 
to  with  advantage,  especially  in  the  reduction  of  labial  protrusion 
of  incisors,  as  in  Fig.  250.  Yet  it  does  not  in  practice  lessen  the 
amount  of  force  required,  nor  hasten  the  movement  of  teeth  to  a 
degree  proportionate  to  the  plausibility  of  the  theory.  Doubtless 
if  the  only  obstacle  to  tooth  movement  were  the  resistance  of  the 
bone  the  operation  would  be  greatly  hastened  by  its  removal,  but 
when  we  remember  the  firm  resistance  offered  by  the  fibers  of  the 
peridental  membrane  by  their  attachment  to  the  plate  of  bone  in  the 
rear  of  the  moving  teeth,  as  well  as  on  all  sides,  this  is  readily  un- 
derstood. 

The  surgical  removal  of  bone  should  always  be  performed  with 
care,  judgment,  and  skill.  It  is  highly  important  that  only  sharp, 
clean  fissure-burs  of  medium  diameter,  with  end  cut,  and  which 
have  been  thoroughly  sterilized,  be  employed,  and  that  the  peri- 


OPERATIVE    SURGERY.  175 

dental  membrane  shall  not  be  injured  in  the  operation.  To  insure 
this  a  thin  septum  of  bone  should  be  allowed  to  remain  between  the 
membrane  and  the  cavity  formed.  The  cavity  should  be  crescent- 
shaped,  of  somewhat  greater  length  than  the  diameter  of  the  tooth., 
when  practicable,  and  in  depth  about  two-thirds  the  length  of  the 
root. 

Eesection  of  Peridental  Fibers. — After  a  careful  study  of  the 
fibers  of  the  peridental  membrane,  the  direction  in  which  they  ex- 
tend, and  their  distribution  and  attachment,  and  knowing  the  strong 
resistance  offered  by  them  to  tooth  movement  and  that  they  must 
often  be  forcibly  severed  or  slowly  absorbed  at  their  points  of  at- 
tachment in  order  to  permit  of  tooth  movement,  it  occurred  to  the 
author  that  it  would  be  but  reasonable  and  wholly  in  keeping  with 
good  practice  to  surgically  sever  them.  Acting  upon  the  belief  he 
has  adopted  the  practice  in  a  number  of  cases  with,  he  thinks,  real 
success,  for  the  force  and  time  necessary  in  tooth  movement  were 
much  lessened  and  as  yet  no  evil  results  have  appeared.  He  would 
earnestly  caution  conservatism,  however,  advising  the  severance  of 
only  such  fibers  as  would  most  probably  be  severed  by  absorption. 
The  only  unpleasant  result  seemingly  conceivable  is  a  possible 
invitation  to  the  development  of  a  degeneracy  of  the  membrane  and 
the  formation  of  septic  pockets.  But  this  is  only,  a  possibility,  and 
then,  perhaps,  only  in  cases  especially  susceptible  by  reason  of 
heredity.  We  must  remember,  too,  that  many  have  advocated  the 
complete  severing  of  all  of  the  attachments  by  extraction  and  re- 
placement of  the  tooth  for  the  cure  of  pyorrhea  alveolaris. 

At  first  thought  it  might  seem  to  be  a  painful  operation.  In 
reality  it  is  very  simple  and  nearly  painless,  provided  it  be  properly 
performed,  with  suitable  instruments.  The  form  of  instrument  is 
of  much  importance.  The  author  experienced  much  difficulty  in 
finding  those  of  sufficient  delicacy  and  proper  temper.  He  knows 
of  no  suitable  form  of  knife  or  bistoury  used  in  dentistry  or  in 
surgery,  until  we  reach  that  of  the  eye,  and  then  only  those  used 
in  the  most  delicate  of  all  surgical  operations, — that  upon  the 
iris,  or  for  removal  of  cataract, — the  instruments  known  as  the 
iris  needle  and  cataract  knife.  These  seem  to  be  most  perfectly 
adapted  for  operations  on  the  peridental  membrane  as  well. 
They  are  extremely  sharp  and  delicate.  They  are  illustrated  in 
Fig.  169. 


176 


MALOCCLUSION. 


In  their  use,  if  we  wish  to  sever  the  principal  obstructing  fibers 
of  a  tooth,  as  for  example  those  which  resist  rotation,  Fig.  170,  we 
have  but  to  pass  them  down  along  the  angle  of  the  root  with  but 


FIG.  169. 


FIG.   170. 


little  more  effort,  and  perhaps  causing  no  greater  pain,  than  would 
follow  the  insertion  of  a  fine,  smooth  broach.     In  their  use  it  has 


OPERATIVE    SURGERY.  177 

been  found  better  to  first  adjust  the  regulating  appliances  and  allow 
them  to  exert  tension  for  two  or  three  days,  that  the  fibers  might 
be  well  tightened  by  stretching.  This  facilitates  insertion  of  the 
delicate  blade  and  makes  the  severing  of  the  fibers  more  complete. 

In  retraction  of  the  cuspid  the  severing  of  the  fibers  in  the  rear 
of  the  tooth  to  the  depth  of  one-third  the  length  of  the  root  seems  to 
be  sufficient  to  greatly  expedite  the  movement. 

We  believe  that  in  suitable  cases  the  duration  and  difficulty  of 
the  movement  may  be  lessened  fully  one-half  by  the  intelligent 
combination  of  methods, — the  surgical  severing  of  fibers  and  re- 
moval of  bone,  in  connection  with  the  use  of  the  regulating  appli- 
ances. 

Section  of  Frenum  Labium. — A  form  of  malocclusion  character- 
ized by  a  space  between  the  upper  central  incisors  (and  rarely  be- 
tween the  lower  centrals)  is  quite  frequently  encountered. 

This  space  may  vary  from  one  to  four  or  even  five  millimeters, 
and  always  attracts  unfavorable  attention  and  interferes  with  speech 
in  proportion  to  its  width. 

The  closing  of  this  space  by  drawing  together  the  incisors  is  a 
comparatively  simple  operation,  requiring  only  a  few  hours,  or  days 
at  most.  But  notwithstanding  the  ease  with  which  these  spaces  may 
be  closed  they  are  yet  well  known  to  be  unsatisfactory  and  annoying 
cases  to  treat,  on  account  of  the  difficulty  of  permanently  estab- 
lishing the  teeth  in  their  corrected  positions.  For  it  is  usually 
found,  even  after  months  of  the  most  perfect  support  by  the  retain- 
ing device,  that  following  its  removal  the  teeth  will  rapidly  separate 
and  assume  their  former  positions.  By  a  more  careful  study  of 
these  cases  the  reason  for  this  becomes  obvious, — the  cause  has  not 
been  removed,  which,  as  we  have  shown  in  the  chapter  on  Etiology  > 
is  usually  due  to  abnormal  development  and  attachment  of  the 
frenum  labium,  Fig.  171. 

It  is  evident  that  the  portion  of  the  ligament  passing  between 
the  teeth  must  be  removed,  or  so  modified  that  it  will  no  longer 
act  mechanically  upon  them. 

The  author  has  derived  partial  success  by  the  mere  severing  of 

the  ligament  with  a  pair  of  delicate  scissors,  union  of  the  ends  while 

healing   being   prevented    by    occasional    manipulation.     But    the 

plan  now  followed  by  him,*  and  which  offers  promising  results,  is 

*Dental  Cosmos,  November,  1899. 

13 


178  MALOCCLUSION. 

to  take  advantage  of  the  contraction  of  tissue  resulting  from  actual 
cautery,  as  rhinologists  do  in  operations  on  the  nose  for  deflected 
septum. 

FIG-  I"1-  FIG.  172. 


With  a  suitable  lancet  or  bistoury  a  deep  incision  is 
made  between  the  teeth,  splitting  the  ligament,  after 
which  an  electro-cautery  knife,  Fig.  172,  at  white  heat, 
is  passed  through  the  incision. 

No  pain  will  be  occasioned  if,  preliminary  to  the  opera- 
tion, the  tissue  be  locally  anesthetized  with  a  proper 
solution  of  cocain,  applied  by  means  of  a  pledget  of  cot- 
ton for  about  ten  minutes.  Great  care  should  be  exer- 
cised in  the  use  of  the  cautery  instrument,  which  should 
come  in  contact  only  with  the  abnormal  tissue,  the 
wounding  of  the  peridental  membrane  being  rigidly 
avoided,  and  for  this  reason  the  clean  incision  is  first 
made  to  simplify  the  operation. 

The  teeth  should  be  drawn  together  and  mechanically 
supported  for  several  weeks  or  months.  The  author's 
favorite  method  of  closing  the  space  is  by  the  exertion  of 
pressure  by  means  of  a  wire  ligature  occasionally  tight- 
ened by  twisting  or  renewal,  it  being  made  to  encircle 
two  spurs  one-thirty-second  of  an  inch  long,  soldered  to 
the  mesio-labial  angles  of  accurately  fitting  bands 
cemented  upon  the  teeth  to  be  moved,  Fig.  173.  The 
bands  should  be  in  position  before  the  operation. 

This  same  device  is  very  satisfactory  for  retention,  or 
the  bands  may  be  removed  and  replaced  by  similar  bands 


OPERATIVE    SURGERY.  179 

joined  by  solder.  Retention  may  also  be  effected  by  a  plate  cover- 
ing- the  anterior  part  of  the  vault  of  the  arch,  having  finger-like 
projections  of  metal  bearing  against  the  distal  surfaces  of  the  central 
incisors. 

Although  the  contraction  due  to  the  cicatricial  tissue  is  con- 
siderable, yet  when  we  remember  the  character  and  structure  of 
the  peridental  membrane  and  the  immense  number  of  normal  fibers 
acting  to  combat  this  tendency,  and  that  they  are  practically  double 
in  these  cases,  for  two  teeth  are  involved,  the  necessity  of  support 
for  a  considerable  length  of  time  (a  year  and  a  half  in  some  cases) 
-should  occasion  no  surprise. 


Double  Resection  of  Maxilla. — Several  years  ago  the  author  be- 
came convinced  that  no  operation  depending  upon  tooth  move- 
ment alone  could  establish  proper  relations  of  the  teeth  or  ma- 
terially improve  the  facial  lines  in  certain  cases  of  pronounced  over- 
development of  the  inferior  maxilla.  It  seemed  to  him  that  such 
cases  might  be  successfully  treated  by  the  removal  of  a  section  of 
bone  from  each  of  the  lateral  halves,  although  the  operation  was  not 
contemplated  except  as  a  remedy  for  the  most  aggravated  condi- 
tions, as  illustrated  in  Figs.  174  and  175. 

The  removal  of  a  single  complete  section  of  the  jaw  had  been 
reported  in  numerous  operations  for  the  relief  of  ankylosis,  tu- 
mors, gunshot  wounds,  etc.,  but  a  search  of  the  literature  failed 
to  reveal  any  instance  of  the  removal  of  complete  sections  from 
each  of  the  lateral  halves. 

The  author's  proposition  was  discussed  with  surgeons  and  den- 
tists, and  was  decided  to  be  feasible.  It  was  as  follows :  Careful 


i8o 


MALOCCLUSION. 


photographs  should  be  first  taken  of  the  patient,  and  two  accurate 
models  be  made  of  the  lower  dental  arch  and  one  of  the  upper 

FIG.  174. 


FIG.  175- 


E.H.A 


OPERATIVE    SURGERY. 


181 


which  should  show  the  forms  of  gums  and  jaws  as  far  as  possible. 
One  of  the  plaster  models  of  the  lower  jaw  should  then  be  sawed 
through  and  the  sections  removed.  The  positions  and  extent  of 
these  sections  should  be  carefully  experimented  with  until  the  three 
remaining  sections  of  the  model  could  be  made  to  best  harmonize 
with  the  upper  arch,  that  the  teeth  might  be  in  best  possible  oc- 
clusion with  those  of  the  upper  jaw.  These  sections  of  the  plaster 
model  should  then  be  cemented  or  waxed  together,  and  over  this 
reconstructed  model  a  vulcanite  or  metal  splint  should  then  be 
formed,  as  shown  in  Fig.  176,  and  by  careful  comparisons  and  meas- 

FIG.  176. 


urements  of  the  reconstructed  model  with  the  unchanged  model 
the  exact  size  and  form  of  both  sections  of  bone  to  be  removed 
should  be  determined,  so  that  there  might  be  no  guessing  as  to  the 
relations  of  the  bone,  and  complete  apposition  of  the  ends  be  made 
possible. 

As  there  is  more  or  less  lingual  inclination  of  the  lower  incisors 
in  all  of  these  cases  (most  pronounced  in  some),  it  is  certain  that 
the  sections  of  bone  to  be  removed  must  not  be  parallel  on  their 
sides,  but  more  or  less  wedge-  or  V-shaped,  if  we  would  gain  the 
best  positions  for  occlusion  of  the  incisors,  as  well  as  for  appearance 
of  the  chin.  The  degree  of  variation  from  the  parallel  of  the  lines 
of  section  must  be  determined  by  the  conditions,  perhaps  never  to 


l82  MALOCCLUSION. 

so  great  an  extent  as  indicated  by  the  dotted  lines  in  Fig.  175, 
which  were  exaggerated  in  the  engraving. 

The  teeth  having  been  thoroughly  cleansed  just  previous  to  the 
operation,  and  the  splint  in  readiness,  the  sections  of  bone  corre- 
sponding accurately  to  those  determined  upon,  as  already  de- 
scribed, should  be  removed,  the  anterior  section  placed  in  apposi- 
tion with  the  posterior  sections,  and  the  splint  fixed  in  position 
upon  the  teeth  with  thinly  mixed  oxyphosphate  cement.  If  the 
operation  be  skillfully  performed  the  most  rigid  support  should  be 
given  to  the  reconstructed  jaw,  far  more  efficient  and  more  in 
keeping  with  modern  aseptic  surgery  than  is  possible  with  that 
crude,  unstable,  and  unmechanical  plan  of  wiring  the  ends  of  the 
bone  together,  so  often  employed  in  the  reduction  of  fractures. 

The  question  most  often  raised  by  dentists  in  discussing  the 
practicability  of  the  operation  as  here  outlined  was  the  uncertainty 
as  to  union  of  the  bones  and  as  to  impairment  of  vitality  of  the 
teeth  in  the  middle  segment.  These  doubts  have'  since  been  set  at 
rest  by  two  operations.  June  23,  1897,  the  author  assisted  the  late 
Professor  Henry  H.  Mudd  in  one  of  these  operations  performed  at 
St.  Luke's  Hospital,  St.  Louis,  upon  Miss  M.  J.,  of  Arkansas,  a 
delicate  girl  thirteen  years  old. 

She  had  suffered,  when  a  child  aged  three  years,  with  some 
acute  inflammation  of  the  mouth,  probably  septic  in  character. 
She  had  exfoliation  of  some  portion  of  the  lower  jaw  at  that  time,, 
and  a  number  of  the  teeth  dropped  out.  She  had  also  an  abscess 
on  the  index  finger,  with  loss  of  bone,  and  some  sores  developed 
on  the  legs.  There  was  no  history  of  any  specific  trouble. 

As  a  result  of  the  inflammation  of  the  mouth  the  lower  jaw  be- 
came fixed  and  firmly  closed  by  cicatricial  contractions.  At  the 
time  of  admission  to  the  hospital  there  was  some  slight  motion  of 
the  temporo-maxillary  articulation  on  each  side.  There  was,  how- 
ever, scarcely  a  perceptible  movement  of  the  body  of  the  jaw. 

The  upper  jaw  was  perhaps  normal  as  to  size,  with  arch  some- 
what narrowed  and  containing  the  full  complement  of  teeth,  though 
somewhat  irregular  as  to  positions.  The  lower  jaw  was  deformed ; 
the  ramus  of  the  jaw  on  each  side  passed  downward  and  back- 
ward so  that  the  angle  of  the  jaw  came  a  little  behind  rather  than 
in  front  of  a  vertical  line  dropped  from  the  lobe  of  the  ear.  The 
arch  of  the  lower  maxilla  was  broadened,  and  the  incisor  teeth  were 


OPERATIVE    SURGERY.  183 

pressed  up  inside  of  the  arch  of  the  upper  jaw  so  that  the  mucous 
surface  of  the  palate  was  injured.  The  teeth  of  the  lower  jaw  were 
irregular  as  to  number  and  positions,  and  the  molars  undersized 
and  defective  in  development.  The  deciduous  first  molars,  very 
diminutive  in  size  both  as  to  crowns  and  roots,  were  still  intact. 
The  permanent  cuspids  and  incisors,  however,  had  developed  nor- 
mally, and  the  incisors  occluded  distally  to  the  upper  incisors  fully 
an  inch. 

The  widening  of  the  arch  and  the  pushing  back  of  the  angle  of 
the  jaw  were,  it  is  thought,  produced  by  the  suction  action  of  the 
child  in  the  endeavor  to  get  food  into  the  mouth.  The  only  point  of 
entrance  for  food  was  the  opening  under  the  arch  of  the  hard  palate 
above  the  incisor  teeth  of  the  lower  jaw.  This  suction  of  the  jaw 
cultivated  very  markedly  the  extrinsic  muscles  of  the  larynx,  as 
well  as  the  depressors  of  the  jaw. 

In  order  to  free  the  body  of  the  jaw  so  that  the  mouth  might  be 
opened,  a  triangular  segment  with  the  base  downward,  the  apex 
upward  and  forward,  was  removed  from  the  angle  of  the  jaw  on 
each  side.  A  complete  section  of  the  bone  was  thus  removed  in 
order  to  secure  false  joints  at  the  junction  of  the  ramus  and  the 
body  of  the  jaw. 

When  the  bone  was  separated,  the  tongue  and  jaw  dropped  down 
so  markedly  that  respiration  was  difficult  and  obstruction  marked. 
Tracheotomy  was  made  in  order  to  insure  free  respiration;  the 
breathing  was  not  relieved  by  simply  holding  forward  the  tongue, 
but  it  improved  when  the  jaw  was  held  upward  and  forward.  This 
was  easily  accomplished  by  means  of  wire  ligatures  made  to  encircle 
the  buttons  on  the  fracture  bands  No.  3,  which  had  been  placed 
upon  the  four  cuspid  teeth,  as  described  in  the  treatment  of  frac- 
tures of  the  maxilla,  and  illustrated  in  Fig.  285.  The  ligatures 
were  occasionally  removed  and  movement  of  the  jaw  made,  in 
order  to  establish  a  hinge  joint  instead  of  osseous  union  of  the  bone. 

The  patient  made  a  rapid  recovery  and  left  the  hospital  in  a 
few  weeks,  when  further  record  of  the  case  was  lost.  At  that  time 
there  was  no  indication  of  the  circulation  or  vitality  of  the  anterior 
teeth  or  segment  of  bone  having  been  impaired. 

Double  resection  for  the  purpose  of  shortening  the  jaw  was 
recently  performed  successfully  at  the  Baptist  Hospital,  St.  Louis.* 
*Dental  Cosmos,  July  and  August,  1898. 


184  MALOCCLUSION. 

Such  an  operation  might  at  first  seem  formidable,  but  there  is  no 
reason  why,  if  skillfully  performed  according  to  modern  aseptic 
methods  of  surgery  and  the  plan  first  indicated,  the  clean,  smooth 
ends  of  the  bone  would  not  unite  at  least  as  readily  as  they  do  in 
the  common  cases  of  double  fractures,  and  the  result  be  nearly 
ideal.  But  the  author  would  earnestly  plead  against  the  practice 
of  wiring  the  ends  of  the  bone  together  after  the  usual  plan  of 
surgeons,  as  the  most  serious  results  must  certainly  follow.  One 
such  failure  has  already  been  reported. 


CHAPTER    XV. 

PHYSIOLOGICAL    CHANGES    SUBSEQUENT   TO   TOOTH    MOVEMENT. 

So  far  we  have  considered  the  physiological  changes  which  take 
place  in  the  tissues  during  tooth  movement,  but  we  must  remember 
that  certain  changes  also  occur  subsequent  to  tooth  movement.  To 
better  understand  these  changes  we  must  keep  in  mind  the  condi- 
tions previously  existent.  The  development  of  malocclusion  is 
gradual,  and  in  proportion  as  the  functions  and  positions  of  the  teeth 
deviate  from  the  normal  is  necessitated  a  corresponding  deviation 
in  the  development  of  the  alveolus,  and,  to  a  greater  or  less  degree, 
in  the  bones  of  the  jaws,  vault  of  the  arch,  the  nasal  tract,  and  the 
muscles  of  the  face.  All  being  out  of  harmony,  the  tendency  is 
usually  to  favor  still  greater  inharmony,  or  departure  from  the  nor- 
mal, as  growth  and  development  progress. 

After  the  crowns  of  the  teeth  have  been  moved  into  correct  posi- 
tions in  the  line  of  occlusion  and  harmony  of  the  occlusal  planes 
established,  the  positions  of  the  teeth  and  function  of  the  occlusal 
planes  have  been  so  changed  as  to  exert  a  different  influence  upon 
the  bones  and  muscles.  The  tendency  now  is  to  assist  and  stimu- 
late Nature  to  efforts  toward  the  rearrangement  of  these  tissues  and 
their  normal  growth  and  development,  in  accordance  with  the 
demands  of  the  teeth  in  their  new  positions  and  with  her  original 
design.  Evidences  are  common  throughout  surgery  of  Nature's 
wonderful  inherent  power  to  remedy  her  defects,  and  of  her  prompt 
response  as  soon  as  favorable  conditions  for  self-assertion  have 


PHYSIOLOGICAL   CHANGES   SUBSEQUENT   TO   TOOTH    MOVEMENT.       185 

been  established.     The  natural  changes  following  the  intelligent 
correction  of  malocclusion  are  often  pronounced  and  gratifying. 

The  cognizance  of  the  possibilities  of  these  changes  should, 
in  many  instances,  modify  our  plan  of  treatment  from  what  it  would 
be  were  we  in  ignorance  of  them.  Very  frequently  where  there  has 
been  change  of  position  of  a  number  of  teeth,  especially  in  both 
arches,  some  may  occupy  planes  of  greater  elevation  than  others,  or 
the  cusps  of  some  may  not  occupy  exactly  normal  mesio-distal  rela- 
tions, but  if  we  have  succeeded  in  placing  the  teeth  so  that  the 
inclined  planes  of  their  occlusal  surfaces  favor  their  normal  posi- 
tions, their  proper  heights  and  relations  will  become  established  as 
a  result  of  occlusion.  In  some  cases  the  incisors  may  apparently 


FIG.  177. 


FIG.  178. 


be  too  short,  but  after  a  few  weeks  or  months,  when  the  teeth  shall 
have  become  settled  in  their  new  positions,  the  length  of  overbite 
of  incisors  may  be  normal. 

Another  noticeable  and  important  change  is  that  following  the 
movement  labially  of  the  crowns  of  a  number  of  incisors,  as  in 
Fig.  177.  The  crowded  and  bunched  positions  of  the  incisors 
have  necessitated  marked  arrest  in  the  development  of  the  alveolus 
in  the  region  of  their  apices,  so  that  after  correction  they  are  found 
to  stand  at  a  very  pronounced  angle,  with  an  abnormal  depression 
in  the  region  of  the  apices  of  their  roots,  Fig.  178,  and  an  apparent 
overprominence  of  the  lip,  often  suggesting  the  impossibility  of 
their  being  maintained  in  such  positions  and  the  desirability  of  ex- 
traction in  order  to  reduce  this  prominence ;  but  in  all  probability, 
at  least  in  a  large  percentage  of  cases,  the  apparent  prominence  is 
due  to  lack  of  development  of  the  alveolus  and  the  lingual  posi- 
tions of  the  apices  of  the  roots,  which  have  developed  thus  in  ac- 
cordance with  the  demands  of  the  teeth  in  malocclusion. 


1 86  MALOCCLUSION. 

The  crowns  of  the  teeth  now  being  in  normal  occlusion,  nature 
is  stimulated  to  continue  the  development  of  the  alveolus,  and  to 
shift  labially  to  normal  positions  the  apices  of  the  roots,  so  that 
in  due  time  there  will  be  the  full  normal  contour  of  the  alveolus 
and  the  teeth  will  stand  at  a  normal  angle,  the  result  being  a 
corresponding  improvement  in  the  contour  of  the  face  in  the  region 
of  the  base  of  the  nose, — a  far  better  result  than  could  have  taken 
place  had  extraction  been  resorted  to. 

The  changes  here  outlined  are  shown  to  have  taken  place  in 
Fig.  179,  which  represents  a  model  of  the  corrected  case  three  years 
later  than  that  shown  in  Fig.  178. 

FIG.  179. 


The  same  changes  also  followed  in  the  cases  shown  in  Figs.  184, 
1 86,  189,  and  209. 

It  is  quite  probable  that  while  the  development  of  the  alveolus 
was  progressing  a  change  in  the  positions  of  the  crowns  of  the 
teeth  of  both  arches  was  also  being  effected,  there  being  a  slight 
movement  distally  on  account  of  the  increase  of  lip  pressure  due  to 
the  more  prominent  positions  of  the  incisors.  This,  however, 
could  not  have  occurred  unless  there  had  been  full  normal  function 
of  the  lips,  accompanied  by  habitual  nasal  breathing. 

The  author  would  not  be  understood  as  asserting  that  extrac- 
tion in  cases  of  this  character  is  never  necessary.  This  phase  of  the 
question  will  be  discussed  under  the  chapter  on  treatment  of  cases 
belonging  to  Class  i.  What  we  especially  wish  to  impress  is  the 
careful  consideration  of  the  possible  changes  following  tooth 
movement  in  all  such  cases,  and  the  requirements  of  the  facial 
lines. 


PHYSIOLOGICAL    CHANGES    SUBSEQUENT   TO   TOOTH    MOVEMENT.       l8/ 

Again,  where  one  or  both  of  the  lateral  halves  of  the  upper 
arch  have  developed  with  the  teeth  in  lingual  occlusion,  the  result 
is  to  prevent  the  normal  development  and  width  of  the  arch,  as  in 
Fig.  1 80. 

It  will  be  observed  that  force  incident  to  mastication  is  brought 
to  bear  upon  the  crowns  at  an  abnormal  angle  to  their  axes.  In- 
stead of  being  received  upon  the  buccal  cusps  of  the  lower  molars 
it  is  received  upon  the  lingual  cusps,  the  tendency  being  to  cause 
a  gradual  divergence  of  the  roots  of  these  teeth  at  their  apices, 
while  the  opposite  is  the  effect  in  the  upper  arch,  the  force  being 

FIG.  180. 


received  upon  the  buccal  cusps  instead  of  the  lingual,  the  tendency 
being  to  cause  convergence  of  the  apices  of  the  roots  of  the  molars 
of  the  lateral  halves,  with  pronounced  perversion  in  the  develop- 
ment of  the  alveolus  and  of  the  jaws,  and  with  abnormal  height  of 
the  vault  of  the  arch. 

Following  the  labial  tipping  movement  of  the  crowns  of  the  up- 
per molars  and  the  lingual  tipping  movement  of  those  of  the  lower. 
as  described  in  the  last  chapter,  the  force  of  occlusion  will  be  re- 
ceived at  the  proper  angle  with  the  axes  of  the  teeth,  or  principally 
upon  the  buccal  cusps  of  the  lower  molars  and  lingual  cusps  of  the 
upper  molars,  the  tendency  being  to  cause  divergence  of  the  apices 
of  the  roots  of  the  upper  molars  and  convergence  of  those  of  the 
lower,  nature  being  thus  permitted  to  continue  the  development 
normally  of  the  bones.  In  the  case  described  marked  changes  fol- 


1 88  MALOCCLUSION. 

lowed.  The  width  of  the  face  in  the  region  of  the  upper  jaw  was 
perceptibly  increased,  and  diminished  in  that  of  the  lower,  with  a 
corresponding  improvement  in  the  vault  of  the  arch  and  function  of 
the  nose. 

There  are  also  noticeable  changes  following  the  reduction  of 
marked  prominence  of  the  upper  incisors,  as  in  those  cases  belong- 
ing to  Division  i  of  Class  II.  As  the  crowns  of  the  incisors  are 
moved  lingually  the  apices  of  the  roots,  as  we  have  already  noted; 
are  moved  to  some  extent  in  the  opposite  direction,  which  is  evinced 
by  more  or  less  of  a  fluted  appearance  of  the  alveolus  in  the  region 
of  their  apices,  and  to  some  extent,  a  greater  prominence  of  the  lip 
in  the  region  of  the  base  of  the  nose ;  but  if  normal  functions  of  the 
nose  and  lip  have  been  established  there  will  follow  a  return  of 
the  apices  to  their  normal  positions,  with  corresponding  normal  de- 
velopment of  the  alveolus  surrounding  them  and  a  corresponding 
lessening  of  the  prominence  of  the  tissues  at  the  base  of  the  nose. 

We  will  have  occasion  to  mention  other  changes  following  tooth 
movement  in  connection  with  cases  discussed  under  treatment. 


CHAPTER   XVI. 

AGE   APPROPRIATE    FOR   TREATMENT. 

THE  age  at  which  the  correction  of  malocclusion  may  be  accom- 
plished extends  over  quite  a  wide  range  of  years.  All  agree  that 
the  positions  of  teeth  may  be  more  readily  changed  in  early  child- 
hood (from  seven  to  twelve  years  of  age)  than  in  any  other  period, 
yet  it  is  argued  by  many  authors  and  practitioners  that  this  is  a 
most  unpromising  age  for  treatment,  as  a  young  child  will  not 
endure  suffering  or  inconvenience,  and  is  lacking  in  the  power  to 
appreciate  our  efforts  in  its  behalf.  Much  is  recorded  in  the  litera- 
ture favoring  the  period  of  life  between  the  ages  of  twelve  and 
seventeen  years,  it  being  argued  that  as  the  operation  is  such  a  long 
and  painful  one  it  is  useless  to  begin  treatment  before  the  child  has 
arrived  at  an  age  when  pride  begins  to  assert  itself.  Then,  it  is 
argued,  the  regulating  appliance  would  be  worn,  the  inconvenience 


AGE    APPROPRIATE    FOR    TREATMENT.  189 

tolerated,  and  the  pain  endured,  consequently  the  hope  of  success 
would  be  greater  than  with  children  younger.  Again  it  is  argued 
that  as  the  operation  is  such  a  painful  one  this  age  has  its  dis- 
advantages, especially  with  girls,  being  a  critical  period  in  their 
history,  the  physical  economy  being  already  severely  taxed. 

Doubtless  there  has  been  some  reason  for  the  above  arguments 
in  the  past,  for  the  awkward,  bulky,  and  inconvenient  appliances 
generally  used  always  caused  much  annoyance  and  often  real  suf- 
fering to  the  patient.  Owing  to  their  faulty  principles  of  construc- 
tion they  were  necessarily  very  slow  in  bringing  about  desired  re- 
sults, often  prolonging  the  operation  over  a  period  of  many  months, 
or  even  years.  It  is  therefore  but  little  wonder  that  young  children 
refused  to  endure  them — that  only  those  pushed  on  by  pride  could 
be  induced  to  persist  in  their  use — and  that  patients  of  delicate  con- 
stitution were  deterred  from  wearing  them  altogether,  for  fear  of 
permanent  constitutional  injury.  The  author  believes  there  is  no 
longer  just  reason  for  such  arguments,  except  as  they  may  apply 
in  connection  with  the  similar  appliances  to  some  extent  still  in 
use. 

A  properly  constructed  appliance,  properly  adjusted  and  oper- 
ated, should  occasion  but  little  more  than  inconvenience  and 
should  bring  about  desirable  results,  usually,  in  a  very  few  weeks. 
The  inflicting  of  real  pain  and  suffering  is  not  only  unnecessary, 
but  is  reprehensible.  Any  young  miss  may  undergo  an  operation 
for  the  correction  of  malocclusion,  even  though  extensive,  without 
any  fear  of  impairing  her  health.  The  author  has  constantly  in  his 
practice  a  large  number  of  young  misses,  many  of  them  quite  deli- 
cate by  nature,  and  he  has  yet  to  notice  that  they  have  in  any  way 
sustained  physical  injury  or  that  they  have  been  made  more  nervous 
or  irritable  by  wearing  the  regulating  appliances.  And  instead  of 
finding  young  children  lacking  in  appreciation  he  greatly  prefers 
such  patients  to  all  others,  for  if  they  are  not  hurt  and  can  see 
satisfactory  results  taking  place  they  become  our  most  willing  and 
appreciative  patients.  The  ease  and  rapidity  with  which  their  teeth 
can  be  moved  at  this  tender  age  should  make  it  the  one  most  desira- 
ble time  of  life  for  the  correction  of  malocclusion.  The  author  is 
more  and  more  impressed  with  the  advantages  of  beginning  the 
treatment  early,  just  as  soon  as  the  irregularities  are  manifest  and 
the  teeth  have  emerged  from  the  gums  sufficiently  to  admit  of  mak- 


190  MALOCCLUSION. 

ing  suitable  attachments.  Then  nature  is  putting  forth  her  best  ef- 
forts; then  growth  and  repair  are  most  rapid  and  the  surrounding 
tissues  most  yielding;  then  slight  force  is  sufficient  to  gently  direct 
each  erupting  tooth  into  its  correct  relation  with  the  line  of  oc- 
clusion. 

Unless  some  unusual  physical  condition  of  the  patient  exist  it 
is  unquestionably  a  serious  mistake,  without  the  least  argument  in 
its  favor,  to  defer  the  operation  until  all  the  teeth  shall  have  erupted, 
as  is  still  so  often  advocated.  By  this  time  the  whole  dental  ap- 
paratus will  have  become  greatly  complicated,  the  teeth  fixed  in 
their  malpositions,  the  facial  lines  badly  marred,  and  the  lips  and 
muscles  modified  to  work  in  harmony  with  the  complicated  mal- 
occlusion,  all  of  which,  in  most  cases,  might  have  been  easily 
avoided  had  the  operation  been  begun  when  irregularities  \vere 
first  manifest. 

There  is  another  reason,  it  would  seem,  in  favor  of  early  treat- 
ment. We  have  already  seen  in  the  study  of  the  alveolar  process 
and  peridental  membrane,  that  in  young  patients  the  sockets  of 
the  teeth  are  large  and  the  intervening  septa  of  bone  often  lacking 
to  a  considerable  extent,  nature  seemingly  waiting  until  the  posi- 
tions of  the  teeth  shall  be  determined  before  completing  her  work. 
Now,  if  the  teeth  be  moved  at  this  time  into  correct  position  the 
normal  deposition  of  bone  and  development  of  the  socket  about  the 
root  of  the  tooth  will  follow,  while  if  movement  be  delayed  until  the 
complete  development  of  the  alveolus,  it  necessitates  extensive  ab- 
sorption, as  well  as  greater  force  in  effecting  the  movement,  and 
the  redeposition  of  bone  may  be  less  stable  in  quality,  or  even  lack- 
ing entirely,  as  we  believe  in  some  instances.  From  experience 
in  a  few  cases  of  attempting  to  correct  malocclusion  which  had  been 
years  before  unsuccessfully  treated,  the  author  has  been  strongly 
impressed  with  the  abnormal  instability  of  the  teeth  which  had 
been  used  for  anchorage.  This  fact,  together  with  the  great  diffi- 
culty in  some  cases  of  maintaining  in  their  new  positions  teeth  that 
have  been  corrected,  even  after  a  long  period  of  retention,  strongly 
suggest  the  possibility  that  the  secondary  deposition  of  bone  may 
never  be  as  stable  as  that  deposited  in  the  normal  period  of  devel- 
opment of  the  alveolus.  Histological  investigations  on  this  point 
are  greatly  needed. 

While,  as  we  have  noted,  the  period  for  the  treatment  of  mal- 


AGE    APPROPRIATE    FOR    TREATMENT.  19! 

occlusion  may  extend  to  maturity,  or,  in  favorable  cases,  much  later, 
yet  we  think  it  may  be  regarded  as  a  law  that  in  proportion  to  the 
age  of  the  patient  are  the  time  required  for  treatment,  the  obstacles 
to  be  overcome,  the  inconvenience,  the  period  of  retention,  and 
uncertainty  as  to  prognosis  increased. 

We    have    pointed    out    elsewhere    the    uselessness    of    delaying 
treatment  with  the  hope  that  nature  will  correct  the  deformity. 

Time  Required  for  Treatment. — One  of  the  questions  usually 
asked  by  patients,  as  well  as  by  dentists,  is  as  to  the  length  of  time 
required  to  complete  the  treatment  of  given  cases  of  malocclusion. 
The  author  believes  it  is  a  mistake  in  most  cases  to  attempt  to  fix 
other  than  in  a  general  way  a  definite  time,  as  the  conditions  and 
requirements  in  orthodontia  vary  greatly  even  in  very  similar  cases, 
and  it  must  be  remembered  that  the  time  for  full  completion  em- 
braces not  only  the  period  of  regulation,  but  the  often  protracted 
period  of  retention.     One  principle  should  be  borne  in  mind,  ap- 
plicable more  especially  to  the  treatment  of  the  teeth  of  young  chil- 
dren, that  our  efforts  should  be  only  to  assist  nature  in  her  efforts 
to  place  the  teeth  in  normal  occlusion.     It  is  now  a  quite  generally 
accepted  theory  that  nature  requires  periods  of  rest  in  the  growth 
and  development  of  the  brain  and  other  portions  of  the  physical 
economy,  probably  in  all,  including  jaws  and  teeth.     So  our  efforts 
in  the  correction  of  malocclusion  may  with  profit,  we  think,  be 
marked  by  periods  of  rest  and  retention.     For  example,  if  an 
erupting  tooth  be  found  deflected,  with  no  probability  of  self-cor- 
rection, it  should  be  moved  into  position  and  the  arches,  one  or 
both,  be  made  to  harmonize  with  the  normal  position  of  the  tooth. 
Delicate,  though  efficient,  retaining  devices  should  then  be  ad- 
justed, followed  by  absolute  rest  from  all  interference,  but  with  oc- 
casional inspection,  until  other  erupting  teeth   may   require  our 
attention.     Or,  if  an  arch  be  found  too  narrow  to  accommodate 
the  erupting  incisors  and  they  be  assuming  malpositions,  the  arch 
should  be  widened,  which  may  usually  be  done  in  a  few  days.     It 
should  then  be  stayed  by  a  delicate  retaining  plate,  with  no  atten- 
tion to  the  incisors  other  than  occasional  inspection,  for,  being  re- 
lieved of  lateral  pressure,  they  will  often  assume  normal  positions 
unaided.     Later,  however,  if  interference  be  found  necessary  their 
correction  may  be  effected. 

So  there  may  be  several  periods  of  activity  and  rest,  which  pos- 


IQ2  MALOCCLUSION. 

sibly  in  some  instances  may  extend  from  the  time  of  eruption  of  the 
lower  permanent  central  incisors  until  the  upper  cuspids  shall  have 
grown  firm  in  their  new  positions. 

It  should  also  be  borne  in  mind  that  long  and  indefinite  periods 
of  wearing  regulating  appliances,  besides  being  unnecessary,  may 
be  fruitful  of  harm.  A  very  few  weeks  will  usually  be  sufficient, 
with  good  appliances  intelligently  managed,  to  accomplish  all  that 
will  be  required  for  any  one  period.  While  what  we  have  said  ap- 
plies more  especially  to  the  treatment  of  teeth  of  young  children, 
we  believe  that  the  same  plan  is  advisable  in  many  cases  of  older 
patients.  After  the  eruption  of  the  teeth,  and  especially  if  the 
cases  be  complicated,  the  treatment  should  be  divided  into  periods 
of  activity  and  rest. 

During  the  period  of  activity  the  tooth  movements  undertaken: 
should  be  fully  accomplished,  and  as  rapidly  as  may  be  consistent 
with  the  physiology  of  tooth  movement.  This  should  be  followed 
by  retention,  with  careful  regard  to  cleansing,  and  complete  rest  for 
several  weeks,  or  even  months,  when  the  remaining  malposed  teeth 
mav  receive  attention. 


CHAPTER   XVII. 

TREATMENT. 

BEFORE  beginning  the  treatment  of  malocclusion  each  case  should 
be  carefully  studied,  noting  the  type  and  temperament  of  the  indi- 
vidual, the  relations  of  the  two  jaws  and  dental  arches  in  compari- 
son with  the  normal,  determining  the  location  of  the  line  of  normal" 
occlusion,  and  noting  such  teeth  as  are  in  normal,  and  also  such 
teeth  as  are  in  abnormal,  relations  therewith ;  also  such  teeth  as  may 
be  missing  through  extraction,  non-eruption,  or  non-development; 
the  facial  lines,  their  variation  from  the  normal  and  how  modified 
by  the  occlusion. 

To  intelligently  understand  these  conditions  may,  in  complicated' 
cases,  often  require  several  visits  from  the  patient,  in  connection 
with  a  careful  study  of  accurately  made  models,  and  in  some  in- 
stances photographs,  which,  studied  in  connection  with  the  models,. 


TREATMENT. 


193 


may  suggest  points  for  consideration  in  subsequent  studies  of  the 
case. 

Skiagraphs,  now  so  easily  and  quickly  made,  are  often  of  great 
value  in  settling  all  doubts  as  to  whether  teeth  be  missing,  or  their 
exact  locations  and  forms  if  merely  imbedded.  While  these  points 
may  be  determined  in  the  majority  of  cases  by  careful  inspection  of 
the  contour  of  the  alveolus  and  digital  pressure,  together  with  the 
use  of  the  exploring  needle,  yet  where  any  doubt  exists  the  skia- 

FIG.  181. 


FIG.  182. 


FIG.  183. 


graph  should  be  resorted  to.  Fig.  181  illustrates  a  case  as  revealed 
by  the  skiagraph  where  the  cuspid  is  so  deeply  imbedded  in  the 
alveolus  as  to  baffle  the  ordinary  methods  of  diagnosis. 

Fig.  182  shows  the  rare  case  of  a  missing  permanent  cuspid,  the 
deciduous  cuspid  being  nearly  ready  to  drop  out,  its  root  having 
been  almost  wholly  absorbed.  The  first  bicuspid  is  about  to  erupt. 

14 


194  MALOCCLUSION. 

The  skiagraph  showed  in  the  opposite  side  of  the  arch  that  the  per- 
manent cuspid  and  first  bicuspid  had  failed  to  develop  and  were 
entirely  missing.  The  deciduous  cuspid,  like  its  fellow  on  the  op- 
posite side,  was  also  about  to  be  lost  through  absorption  of  its  root. 

Fig.  183  shows  another  case,  that  of  a  young  lady  aged  sixteen, 
where  the  left  lateral  incisor  is  entirely  missing.  Additional  in- 
terest is  given  to  this  case  in  the  fact  that  in  a  cousin  of  this  patient 
on  the  father's  side  the  left  upper  lateral  also  failed  to  develop, 
while  the  paternal  grandfather  and  a  sister  have  diminutive,  mal- 
formed laterals,  the  father's  teeth  being  normal  in  development. 

In  the  treatment  of  all  cases  of  malocclusion  our  efforts  should 
be  toward  the  accomplishing  of  three  main  objects : 

First,  correction  of  malocclusion  ; 

Second,  establishment  of  harmony  in  the  relations  of  the  jaws; 

Third,  improvement  of  the  facial  lines. 

In  the  accomplishment  of  these  our  efforts  should  be  toward  the 
ideal,  where  normal  occlusion,  normal  relations  of  jaws,  and  har- 
mony of  facial  lines  are  combined.  While  the  -ideal  is  not  always 
possible  to  gain,  yet  the  best  attainable  results  cannot  be  hoped  for 
with  a  lesser  standard. 

Correction  of  Malocclusion. — It  has  already  been  pointed  out  that 
teeth  are  held  in  their  correct  positions  when  in  normal  occlusion  by 
the  harmonious  relations  of  their  inclined  occlusal  planes.  It  there- 
fore becomes  of  the  greatest  importance  in  the  treatment  of  cases 
of  malocclusion  that  harmony  be  established  in  these  inclined 
planes,  so  that  their  interlocking  will  eventually  keep  each  tooth 
firmly  in  its  corrected  position. 

Recognizing  this  powerful  influence,  then,  it  is  but  folly  to  ex- 
pect teeth  that  have  been  moved  into  harmony  with  their  lines  of 
occlusion  to  remain  longer  than  a  few  weeks  or  months  after  the 
removal  of  the  artificial  support  given  by  the  retaining  devices,  un- 
less harmony  of  the  inclined  occlusal  planes  shall  have  been  estab- 
lished and  consequent  mutual  support  of  the  arches  gained,  or  the 
inclined  occlusal  planes  at  least  placed  in  such  relations  that  the 
final  settling  of  the  teeth  will  bring  them  into  normal  relations. 
Even  the  slight  torso-occlusal  position  of  a  single  tooth,  for  example 
a  lower  cuspid,  must  not  be  overlooked,  but  must  be  readjusted  and 
made  to  occupy  its  full  normal  mesio-distal  space  in  the  arch ;  other- 
wise there  must  necessarily  follow  a  corresponding  diminution  in 


TREATMENT.  195 

the  size  of  the  opposite  arch,  evidenced  by  some  form  of  bunching, 
crowding,  or  overlapping  of  the  teeth.  Let  this  be  remembered  as 
a  law  in  the  correction  of  malocclusion. 

We  should  aim,  as  far  as  may  be  consistent  with  conditions  found 
to  exist  in  each  given  case,  to  place  the  teeth  in  normal  occlusion. 
This,  however,  is  not  always  possible  or  advisable,  for  to  do  so  the 
full  complement  of  teeth  must  be  retained,  which  in  rare  instances 
would  result  in  giving  too  great  prominence  to  the  teeth  and  lips, 
thereby  creating  a  condition  probably  quite  as  unpleasing  as  the 
original.  In  some  instances  with  the  full  complement  of  teeth  it 
may  be  impracticable  to  establish  harmony  in  the  occlusal  inclines, 
as  for  example  in  the  subdivisions  of  all  of  the  classes.  Therefore 
it  becomes  necessary  in  some  cases  to  sacrifice  some  of  the  teeth  in 
order  that  we  may  have  the  best  attainable  degree  of  occlusal  and 
facial  harmony,  in  which  case  the  result  may  be  defined  as  im- 
proved occlusion,  as  distinguished  from  normal  occlusion. 

Harmony  in  Relations  of  Jaws. — The  jaws  are  often  found  in 
abnormal  relations,  and  the  ideal  in  occlusion  of  the  teeth  and  har- 
mony of  facial  lines  cannot  be  attained  without  establishment  of 
normal  relations  of  the  jaws  as  well.  Yet  the  limitations  of  present 
knowledge  do  not,  in  most  cases,  permit  any  great  improvement  in 
their  relations.  We  are  chiefly  limited  to  operating  upon  the  jaws 
indirectly  through  the  teeth,  but  recent  progress  in  orthodontia  and 
surgery  encourages  us  to  hope  for  greater  future  achievements  in 
this  direction.  Much  can  be  accomplished,  however,  even  at 
present,  in  suitable  cases  and  at  the  proper  age, — that  coincident 
with  growth  and  development. 

In  favorable  cases  belonging  to  Classes  II  and  III  we  may 
change  the  position  of  the  lower  jaw  by  moving  it  forward  or  back- 
ward until  the  teeth  are  in  normal  or  improved  relations.  By  main- 
taining it  in  this  position  it  will  in  time  become  modified  or  changed 
in  form,  from  the  influence  of  the  changed  tension  of  the  muscles 
and  changes  in  the  temporo-maxillary  articulation,  to  harmonize 
with  its  new  conditions.  Just  to  what  extent  the  form  of  the  jaw 
changes  is  not  known,  but  there  are  many  instances  in  orthopedic 
surgery  to  prove  that  bone  can  be  bent  and  that  it  is  frequently  so 
modified.  After  maturity  we  are  limited  to  the  shortening  of  the 
jaw  by  the  surgical  operation  of  double  resection  already  described. 

With  the  upper  jaw  the  limits  of  modification  are  still  greater,  by 


JC)6  MALOCCLUSION. 

reason  of  its  immobility.  We  may,  however,  by  the  proper  appli- 
cation of  force  to  the  teeth,  separate  the  superior  maxillary  bones 
at  the  suture,  thereby  perceptibly  increasing  the  width  of  the  jaw 
in  either  the  anterior  or  posterior  region,  thus  improving  its  re- 
lation with  the  lower  jaw,  as  well  as  the  consequent  improvement  of 
the  features.  While  but  little  has  yet  been  done  along  this  line, 
only  a  few  cases  having  been  reported,  yet  there  is  little  doubt  that 
the  scientific  possibilities  are  promising  and  that  with  the  advance 
of  surgery  there  will  be  gratifying  results  from  systematic  efforts. 
The  operation  on  the  cleft  palate,  principally  through  the  jaw,  as 
in  the  Brophy  operation,  is  one  indication  of  the  possibilities  in  its 
modification  and  improvement. 

Another  source  of  improvement  of  their  relations  is  the  develop- 
ment of  the  jaws  subsequent  to  the  correction  of  the  positions  of 
the  teeth  and  the  establishment  of  normal  functions  of  their  occlu- 
sal  planes,  as  discussed  in  the  chapter  on  Changes  Subsequent  to 
Tooth  Movement. 

Harmony  of  Facial  Lines. — Often  the  desire  for  improvement  of 
the  features  is  one  of  the  impelling  motives  for  seeking  the  cor- 
rection of  malocclusion,  and  although  perhaps  secondary  in  im- 
portance to  the  restoration  of  the  normal  functions  of  the  teeth,  yet 
as  symmetry  of  the  facial  lines  is  of  much  consequence,  especially  to 
womankind,  the  possibilities  of  improvement  being  so  great  are 
worthy  of  our  highest  efforts.  The  form  of  the  face  may  be  modi- 
fied by  enlarging  or  diminishing  in  size  one  or  both  of  the  dental 
arches,  thus  often  greatly  altering  the  relation  of  the  lips  with  the 
line  of  harmony,  or  in  favorable  cases  the  lower  jaw  may  even  be 
moved  bodily  forward  or  backward  and  permanently  established  in 
its  new  position,  as  already  stated  and  illustrated  in  Figs.  13  and  280,. 
thereby  placing  the  entire  lower  part  of  the  face  in  greater  harmony. 

The  author  would  not  be  understood  as  advocating  that  the  ef- 
fort should  be  made  to  make  each  face  rigidly  conform  to  the  line 
of  harmony.  The  great  variation  of  facial  types  and  the  limits 
of  the  region  over  which  we  may  exercise  control,  together  with 
the  peculiarity  of  conditions  of  the  teeth,  make  impracticable  such 
a  course.  We  should,  however,  always  have  this  standard  of 
beauty  toward  which  to  direct  our  efforts,  and  should  approach  it 
as  nearly  as  is  consistent  with  all  the  condiiions  found  to  exist  in 
each  given  case. 


TREATMENT.  IQ7 

Having  made  a  thorough  study  and  diagnosis  of  each  case  and 
noted  the  class  to  which  it  belongs,  and  the  desirable,  possible,  and 
practicable  changes,  we  may  then  direct  our  attention  to  the  consid- 
eration of  other  questions,  such  as  anchorage,  the  appliances  best 
suited  for  producing  the  changes,  the  probable  time  necessary  for 
effecting  them,  together  with  the  anticipation  of  the  requirements 
of  retention,  the  probable  adequate  remuneration  for  services,  etc., 
which  can  only  be  approximately  arrived  at  after  the  most  honest 
and  thorough  consideration  of  all  the  lines  we  have  enumerated  re- 
lative to  diagnosis. 

Treatment  of  Cases — Class  I. — As  we  have  already  noted  in  the 
classification  of  malocclusion,  the  number  of  cases  belonging  to  this 
class  is  the  greatest  and  comprises  by  far  the  largest  variety,  the 
distinguishing  characteristic  of  the  class  being  relative  normal  re- 
lations of  the  jaws,  with  molars  in  correct  relation  mesio-distally, 
although  one  or  more  may  be  in  buccal  or  lingual  occlusion.  The 
malposed  teeth  are  usually,  however,  confined  to  those  anterior  to 
the  molars  and  more  commonly  to  the  incisors,  the  dental  arches 
being  smaller  than  normal  and  the  teeth  crowded  and  overlapping. 
Both  arches  are  usually  involved,  and  sometimes  quite  similarly. 

As  the  mesio-distal  relations  of  the  lateral  halves  of  the  dental 
arches  are  normal  in  this  class,  it  must  follow  that  if  the  teeth  of 
each  arch  be  moved  into  harmony  with  their  lines  of  occlusion 
both  arches  must  then  be  in  perfect  harmony  as  to  size  and  the 
teeth  be  in  normal  occlusion. 

'Fig.  184  represents  a  very  common  form  of  malocclusion  belong- 
ing to  this  class.  It  will  be  seen  that  the  mesial  and  distal  inclined 
planes  of  the  mesio-buccal  cusp  of  the  first  upper  molar  on  the 
right  is  received  between  the  inclines  of  the  mesio-  and  disto-buccal 
cusps  of  the  first  lower  molar,  or  that  the  relations  of  the  first  molars 
are  normal.  (The  molars  of  the  opposite  side  were  also  in  normal 
relation.)  The  arches  are  diminished  in  size  and  the  teeth,  espe- 
cially the  incisors,  occupy  positions  lingual  to  normal. 

What  is  then  clearly  indicated  is  that  the  arches  be  enlarged 
and  each  tooth  moved  into  its  correct  position  in  the  line  of  occlu- 
sion, as  shown  in  the  case  when  completed,  Fig.  185,  and  in  the 
plan  of  treatment  of  any  case  belonging  to  Class  I  it  makes  but  little 
difference  what  positions  the  malposed  teeth  may  occupy.  They 
are  always  subject  to  the  one  general  requirement.  In  the  com- 


198 


MALOCCLUSION. 


pleted  case,  as  shown  in  the  engraving,  it  will  be  seen  that  each 
tooth  has  been  placed  in  harmony  with  its  line  of  occlusion  and  is 
therefore  now  in  best  position  to  support  and  be  supported  by  all 

FIG.  184. 


FIG.  185. 


the  remaining  teeth,  as  well  as  to  be  in  nearest  harmony  with  the 
muscles  and  the  normal  facial  lines. 

The  establishment  of  normal  occlusion  may  and  should  be  the 
result  in  by  far  the  largest  percentage  of  cases  belonging  to  this 


TREATMENT.  199 

class,  but  this  is  only  possible  with  the  full  complement  of  teeth. 
There  are  cases,  however  (though  the  author  believes  they  are  very 
few),  in  which  extraction  is  necessary.  Aside  from  those  rare  in- 
stances of  supernumeraries  or  malposed  teeth,  or  where  extrac- 
tion may  be  necessary  to  harmonize  conditions  in  the  arches  re- 
sulting from  previous  losses  or  failure  in  development  of  teeth, 
which  conditions  cannot  be  discussed  according  to  any  general 
rules,  but  must  be  determined  alone  by  the  judgment  of  the  opera- 
tor after  a  most  thorough  consideration  of  all  the  peculiarities,  the 
author  can  conceive  of  but  two  reasons  for  extraction  in  this  class. 

First,  where  the  jaws  are  so  small,  either  naturally  or  because 
of  arrested  development,  that  the  angles  of  inclination  would  be  too 
great  if  all  the  teeth  were  placed  in  line. 

Such  a  case  is  shown  from  both  sides  in  Figs.  186  and  187.  It 
will  be  readily  seen  from  a  study  of  this  case  that  the  upper  jaw  was 
naturally  diminutive  in  size,  giving  marked  labial  inclination  to  all. 

FIG.  186.  FIG.  187. 


of  the  anterior  teeth,  even  in  their  crowded  condition,  and  that  if 
moved  into  correct  alignment  their  protrusion  would  be  exagger- 
ated and  the  result  impracticable. 

Second,  where  extraction  is  necessary  from  the  requirements  of 
the  facial  lines,  for  the  development  of  the  arches  may  be  such  as 
to  afford  an  abundance  of  room  for  the  malposed  teeth,  and  yet  the 
placing  of  them  in  the  line  of  occlusion  may  result  in  marked  dental 
or  labial  prominence,  and  the  facial  result  be  more  unpleasing  than 


2OO 


MALOCCLUSION. 


if  the  teeth  had  been  allowed  to  remain  in  malpositions.     Such  a 
case  is  shown  in  Fig.  188. 

The  author  believes  such  cases  are  much  more  rare  than  seems  to 
be  commonly  supposed,  for  often  where  such  results  at  first  seemed 
probable,  yet  the  conservative  method  being  followed,  after  all  was 
completed  and  the  teeth  had  settled  to  mesio-distal  contact,  the 
features  were  not  too  prominent.  We  should  also  take  into  con- 
sideration in  connection  with  these  cases  the  possible  changes  in 
the  development  of  the  jaws,  as  noted  in  the  chapter  on  Changes 
Subsequent  to  Tooth  Movement. 

FIG.  188. 


It  is  difficult  to  lay  down  any  precise  rule  regarding  extraction, 
but  it  is  a  matter  which  involves  the  broadest  consideration  and 
closest  study  of  each  case,  often  taxing  the  judgment  as  much  as 
does  any  problem  in  orthodontia.  A  rule  which  the  author  has  fol- 
lowed for  some  time,  when  at  all  in  doubt,  is  to  pursue  treatment 
according  to  the  conservative  method,  studying  the  relations  of  the 
dental  arches  and  features  carefully,  until  a  certainty  in  the  matter 
shall  become  apparent. 

Very  often  by  pursuing  this  course  we  shall  find  that  where  ex- 
traction seemed  at  first  imperative,  its  necessity  was  only  apparent, 
and  disappeared  as  treatment  progressed.  If,  however,  it  develop 
that  extraction  be  necessary,  no  harm  will  have  resulted  from 
pursuing  the  conservative  course  first.  But  if  extraction  be  re- 
sorted to  hastily  or  ill-advisedly,  and  afterward  prove  to  have  been 


TREATMENT.  2OI 

a  mistake,  as  would  in  most  instances  be  found  to  be  the  case,  the 
final  effect  on  the  occlusion  or  facial  lines,  or  both,  may  be  such  as 
to  cause  serious  regrets  and  embarrassments. 

The  study  of  such  cases  as  represented  in  Figs.  184,  189,  and  197, 
together  with  that  of  the  tissues,  and  of  changes  subsequent  to  tooth 
movement,  should,  we  think,  be  evidence  not  to  be  passed  lightly 
over  by  those  who  have  so  freely  advocated  extraction. 

There  seems  to  be  much  difference  of  opinion  as  to  choice  of 
teeth  in  case  a  sacrifice  be  necessary.  Either  the  first  or  second 
bicuspids  are  usually  advised,  some  writers  advocating  the  first 
molar,  especially  if  it  be  affected  with  caries,  while  some  have 
extracted  the  lateral  incisor. 

Probably  defective  appliances  have  done  much  in  the  past  toward 
shaping  the  decision  as  to  the  sacrifice  of  teeth, — such  extraction 
being  resorted  to  as  would  best  facilitate  adjustment  of  the  re- 
maining teeth,  regardless  of  their  comparative  value.  The  present 
ease  and  certainty  of  tooth  movement  by  the  use  of  proper  appli- 
ances makes  inexcusable  the  extraction  of  teeth  as  a  help  to  the 
accomplishment  of  results  that  will  not  accord  with  the  demands  of 
the  best  possible  occlusion  and  facial  harmony,  which  alone  should 
be  our  guide. 

We  cannot  understand  how  those  who  have  made  a  careful  study 
of  the  occlusion  of  the  teeth  and  know  their  interdependence  could 
ever  advise  the  removal  of  the  first  molar,  even  though  far  ad- 
vanced with  caries;  for  its  loss  not  only  could  not  benefit  the 
crowded  condition  of  the  incisors,  but  would  probably  be  followed 
by  other  forms  of  malocclusion  even  more  serious ;  while  the  re- 
moval of  a  cuspid  or  lateral  incisor,  unless  the  root  be  malformed 
in  such  manner  as  to  make  its  adjustment  impracticable,  the  author 
believes  to  be  no  longer  excusable  even  in  a  country  physician. 

As  between  the  first  and  second  bicuspids,  their  resemblance  in 
form  is  so  close  as  to  make  the  choice  for  sacrifice  a  matter  of  in- 
difference were  it  not  that  the  loss  of  the  second  bicuspid  greatly 
increases  the  difficulties  of  treatment.  To  remove  one  tooth  in  this 
class  is  to  necessitate  removal  of  the  corresponding  tooth  in  the 
opposite  arch,  as  otherwise  there  would  be  a  resultant  inharmony  in 
the  sizes  of  the  arches,  with  all  its  evils.  To  extract  the  first  upper 
bicuspid  and  one  of  the  lower  incisors,  as  advocated  by  some,  would 
only  lead  to  a  similar  result  of  less  degree,  besides  making  impos- 


202 


MALOCCLUSION. 


sible  the  establishment  of  real  harmony  between  the  occlusal  planes 
of  the  remaining  teeth. 

If  it  be  necessary  to  sacrifice  a  bicuspid  from  a  corresponding 
lateral  half  of  each  arch  in  this  class,  it  by  no  means  follows  that 
similar  sacrifices  must  be  made  from  the  opposite  side.  In  fact, 
such  cases  are  extremely  rare.  Of  course,  extraction  from  one  of 
the  lateral  halves  of  each  arch  necessitates  the  slight  shifting  of  the 

FIG.  180. 


FIG.  190. 


incisors  from  the  median  line  as  the  arches  diminish  in  size.  But 
arches  with  lateral  halves  equally  developed  are  rarely  found.  One 
of  the  sides  will  usually  be  found  to  be  the  more  favorable  to  extrac- 
tion. And  again,  after  completion  of  the  case  and  after  all  the  teeth 
have  become  settled  in  their  new  positions  the  lateral  inclination  of 
the  incisors  is  rarely  noticeable,  and  weighs  naught  in  comparison 
with  the  general  occlusal  and  facial  results. 

Figs.  189,  190,  and  191  illustrate  a  case  in  its  labial,  buccal,  and 


TREATMENT. 


203 


occlusal  aspects,  and  from  the  positions  of  the  cuspids  and  mesio- 
buccal  cusps  of  the  upper  first  molars  it  will  readily  be  recognized  as 
a  typical  case  belonging  to  the  first  class. 

FIG.  191. 


It  will  be  seen  that  the  arches  are  much  shortened  and  reduced 
from  the  normal  size,  with  marked  lingual  positions  of  all  the  in- 
cisors, the  left  upper  lateral  being  in  contact  with  the  first  bicuspid, 
causing  almost  complete  labial  displacement  of  the  left  cuspid, 
while  at  least  one-half  of  the  space  necessary  for  the  right  cuspid 
is  occupied  by  the  right  lateral,  the  influence  of  the  lips  effectually 


204  MALOCCLUSION. 

maintaining  the  diminished  size  of  the  arches  and  the  malocclu- 
sion. 

The  effect,  as  might  be  supposed,  was  very  noticeable  in  the 
facial  lines  of  the  patient,  as  shown  in  Fig.  192,  producing  a  pinched 
and  flattened  appearance  about  the  mouth. 

As  so  much  space  would  be  required  for  admission  of  the 
upper  cuspids  into  the  line  of  occlusion,  the  extraction  of  one 
first  bicuspid  in  this  arch  might  at  first  suggest  itself,  but  the  de- 
velopment of  the  alveolus  and  demands  of  the  facial  lines  were  such 
in  this  case  as  would  have  made  such  a  course  inexcusable.  What 
was  clearly  indicated  was  the  restoration  of  all  the  teeth  to  normal 

FIG.  192. 


occlusion  by  slightly  widening  both  arches,  moving  labially  all  the 
incisors  into  line,  and  performing  elevation,  rotation,  and  a  slight 
lingual  movement  of  the  cuspids. 

Fig.  193  shows  these  various  movements  being  accomplished  in 
both  arches  simultaneously  by  means  of  expansion  arches,  spurred 
bands,  and  wire  ligatures,  adjusted  as  described  in  the  use  of  the 
expansion  arch,  Chapter  XL 

The  anchorage  was  effected  by  means  of  D  bands  placed  upon 
the  first  molars  in  the  lower  arch,  while  in  the  upper  arch  a  D  band 
upon  the  first  molar  was  used  on  the  right  side  and  an  X  band  on 
the  first  bicuspid  on  the  left  side,  it  being  found  necessary  after  a 
few  days  of  treatment  to  transfer  the  anchorage  from  the  left  first 
molar  to  this  tooth,  as  the  molar  showed  displacement  distally  in 
resisting  the  strain  of  the  labial  movement  of  the  incisors. 

It  will  be  noticed  that  there  are  two  ligatures  upon  the  left  lateral 
incisor.  One  is  a  plain  ligature,  as  in  A,  Fig.  63,  for  effecting  the 


TREATMENT. 


205 


labial  movement ;  the  second,  as  in  B,  Fig.  63,  encircles  the  arch 
and  a  spur  soldered  low  down  upon  the  lingual  surface  of  the  band 
upon  the  lateral.  The  office  of  this  ligature  was  partly  to  assist 
in  carrying  the  incisor  forward,  but  principally  to  effect  its  rota- 
tion. A  spur  is  seen  upon  the  expansion  arch  to  prevent  this  liga- 


FIG.  193. 


ture  from  sliding  forward  and  to  direct  the  movement  of  the  tooth 
laterally,  the  arch  being  so  bent  that  in  shape  and  spring  it  bears 
to  the  left  and  favors  this  movement,  assisted  reciprocally  by  the 
band,  spur,  and  ligature  upon  the  right  lateral.  The  reason  for  the 
spurs  being  placed  well  toward  the  gum,  as  is  important  in  all  such 
cases,  is  that  it  resists  the  tendency  of  the  arch  to  slide  toward  the 


2O6  MALOCCLUSION. 

occlusal  edges  of  the  teeth.  This  tendency  is  further  opposed  by 
the  crossing  of  the  ligature  near  the  spur. 

The  right  lateral  is  encircled  by  the  loop  style  of  ligature,  as  in 
C,  Fig.  63,  being  prevented  from  sliding  off  by  the  band. 

The  form  of  the  expansion  arch  was  occasionally  modified  by 
bending  to  meet  the  requirements  of  the  moving  teeth  and  prevent 
bunching. 

Xot  until  the  incisors  had  been  moved  labially  sufficiently  for 
tlu  full  admission  of  the  cuspids  into  the  line  of  occlusion  was  any 
effort  made  toward  elevating  them  in  their  sockets.  This  was 
also  effected  by  enlisting  the  spring  of  the  expansion  arch.  Wire 
ligatures  were  carefully  worked  beneath  the  gum  and  above  the 
gingival  ridges  of  the  cuspids  and  given  one  full  twist  on  the  labial 
surface,  followed  by  a  final  one-fourth  twist  from  the  grasp  of 
the  pliers.  One  of  the  long  ends  was  then  made  to  encircle  the 
arch,  a  second  twist  given,  and  the  ends  clipped  down  to  the  usual 
length,  as  described  in  directions  for  adjusting  ligatures,  Chapter 
VIII.  This  period  in  the  treatment  is  shown  in  the  engraving,  Fig. 
193,  made  from. a  study  model  taken  in  wax  with  the  appliances  in 
position. 

Tension  on  the  cuspids  by  the  spring  of  the  expansion  arch  was 
occasionally  intensified  by  an  additional  twist  in  the  ligatures,  first 
always  pressing  upward  upon  the  arch  with  the  finger  in  order  to 
relieve  the  strain  upon  the  ligature  while  twisting. 

The  movement  of  rotation  being  the  most  difficult,  it  was  de- 
layed until  the  teeth  were  fully  erupted  to  the  line  of  occlusion, 
when  the  spurred  band,  wire  ligature,  and  wedges  of  rubber  were 
applied  after  the  usual  manner  for  accomplishing  the  movement  and 
soon  brought  about  the  desired  results. 

Owing  to  the  lingual  inclination  of  the  crowns  of  the  lower 
incisors  no  bands  were  necessary,  the  ligatures  simply  encircling 
the  expansion  arch  and  crowns  of  the  teeth.  The  lateral  pressure 
from  the  teeth  prevented  the  ligatures  from  sliding  off.  It  will 
be  noted  that  a  spur  upon  the  arch  directed  the  movement  of  the 
cuspid  laterally  as  well  as  labially. 

The  slight  necessary  rotation  of  the  left  second  bicuspid  was  ac- 
complished by  bands,  spurs,  ligatures,  and  rubber  wedges,  as  al- 
ready described,  as  soon  as  the  teeth  anterior  had  been  moved  into 
correct  position  to  reduce  the  crowding  and  permit  it  to  turn. 


TREATMENT. 


2O7 


The  teeth  of  the  upper  arch  were  retained  in  their  new  posi- 
tions by  a  section  of  wire  G  soldered  to  the  mesio-lingual  angles  of 
bands  on  the  cuspids  and  made  to  bear  against  the  lingual  surfaces 
of  the  intervening  incisors,  as  in  Figs.  152  and  212. 

The  lateral  tendency  of  the  lower  cuspid  and  lingual  tendency 
of  the  incisors  were  antagonized  by  a  similar  device,  and  the  cuspid 
was  retained  by  a  band  and  spur,  the  end  bearing  upon  the  lingual 
surface  of  the  first  bicuspid,  as  in  Fig.  154. 

A  combination  of  the  jack-screw,  as  in  Fig.  132,  might  have 
been  employed  in  the  movements  of  the  incisors,  though  perhaps 
with  not  quite  such  perfect  control  of  the  teeth. 

FIG.  194. 


FIG.  195. 


Fig.  194  shows  the  upper  model  of  the  case  soon  after  its  com- 
pletion; Fig.  195  nearly  two  years  later.     And  it  is  interesting  to 


208 


MALOCCLUSION. 


note,  by  comparing  the  two  cuts,  what  a  marked  change  has  oc- 
curred in  the  alveolus  in  the  region  of  the  incisors.  Nature  un- 
aided has  shifted  the  roots  of  these  teeth  to  closely  approximate 
their  ideal  positions. 

Fig.  196  represents  the  face  of  the  patient  at  this  time,  and  the 
improvement  in  the  facial  contour  is  very  noticeable  and  gratifying. 


FIG.  K 


Fig.  197  shows  another  case  similar  to  that  just  described.  The 
main  peculiarities  are  almost  identical,  the  difference  really  con- 
stituting only  one  of  the  ever-varying  combinations  in  the  mal- 
positions taken  by  the  incisors,  with  the  same  general  require- 
ments. 

Fig.  198  shows  the  upper  model  from  the  occlusal  aspect  with 
the  appliances  in  position  at  the  beginning  of  treatment.  It  will 
be  noted  that  each  arch  is  greatly  diminished  in  size,  and  that  there 
is  marked  arrest  in  the  development  of  the  alveolus  in  the  region  of 
the  incisors.  These  teeth  were  moved  labially  in  the  usual  way, 
and  similar  to  that  in  the  case  last  described.  The  same  plan  was. 
also  followed  in  the  correction  of  the  positions  of  the  lower  teeth. 


TREATMENT. 


2O9 


Fig.  199  shows  the  occlusion  of  the  case  after  correction,  with 
retaining  bands  upon  the  cuspids.  All  four  cuspids  were  banded 
and  connected  by  sections  of  G  wire,  as  inrFig.  152. 

FIG.  197. 


FIG.  K 


Figs.  200  and  179  represent  the  upper  model  of  the  case  from  the 
labial  and  occlusal  aspects  three  years  after  the  removal  of  all 
appliances. 

By  comparing  these  with  Figs.  178  and  199  (which  also  represent 
the  same  case),  it  will  be  noted  what  a  remarkable  change  has  taken 

15 


2IO 


MALOCCLUSION. 


place  in  the  development  of  the  alveolus  in  the  region  of  the  incisors. 
There  has  also  been  a  shifting  labially  of  the  apices  of  the  roots  of 
the  incisors  until  these  teeth  occupy  ideal  positions  and  inclinations, 
with  an  equally  gratifying  change  in  the  contour  of  the  face. 

FIG.  199. 


FIG.  200. 


Before  leaving  this  case  one  point  of  interest  should  be  men- 
tioned. It  will  be  seen  in  Fig.  199  that  the  bicuspids  are  in  slight 
infra-occlusion,  but,  as  they  are  perfectly  placed  in  other  respects, 
the  author  deems  it  good  practice,  as  in  all  such  cases,  to  allow  any 


TREATMENT. 


211 


slight  shortness  of  the  teeth  to  be  adjusted  by  nature  lather  than  to 
prolong  treatment  beyond  the  period  necessary  to  the  accomplish- 
ment of  the  essential  principles  in  the  establishment  of  occlusion, 
knowing  full  well  that  this  will  soon  be  effected  and  that  the  in- 
clines of  the  cusps  will  certainly  guide  them  into  correct  positions. 
Figs.  201  and  202  show  the  malocclusion  of  the  teeth  from  the 
labial  and  occlusal  aspects  in  the  case  of  a  patient  ten  years  of  age. 
From  the  position  of  the  deciduous  cuspids  it  will  be  readily  diag- 
nosed as  belonging  to  the  class  under  consideration. 


FIG.  202. 


All  of  the  permanent  incisors  have  fully  erupted  and  occupy 
positions  lingual  to  normal,  while  the  upper  laterals  and  left  cen- 
tral are  in  torso-occlusion  as  well,  the  central  occluding  lingually 


212  MALOCCLUSION. 

to  the  opposing  lower  central.  The  external  muscular  pressure  is 
gradually  narrowing  the  arches,  as  a  result  of  the  diminished  sup- 
port of  their  lateral  halves,  and  ever-increasing  complications  must 
follow  delay  of  treatment,  while  the  occlusal  edges  of  the  teeth  must 
be  injured  by  abnormal  contact. 

The  line  of  treatment  which  should  be  followed  is  practically 
the  same  as  in  the  case  first  described.  By  placing  each  tooth  in 
proper  position,  by  means  of  expansion  arches,  spurred  bands,  and 
wire  ligatures,  we  establish  normal  occlusion. 

Retention  was  effected  by  resisting  the  torso-lingual  tendency 
of  the  incisors  by  two  bands  united  by  solder  and  placed  upon  the 
left  central  and  lateral.  Projecting  from  the  disto-labial  surface 
of  the  band  on  the  lateral  was  a  spur  made  to  bear  against  the 
mesio-labial  surface  of  the  cuspid.  Projecting  from  the  mesio- 
lingual  surface  of  the  band  on  the  central  was  another  spur  which 
extended  across  the  lingual  surface  of  the  right  central  and  lateral, 
and  terminated  in  a  pit  in  the  mesio-lingual  surface  of  the  tem- 
porary cuspid. 

The  lingual  tendency  of  the  lower  incisors  was  resisted  by  the 
same  device  as  in  the  case  last  described,  shown  in  Fig.  152. 

Fig.  203  shows  another  more  or  less  common  type  of  malocclu- 
sion  belonging  to  this  class,  as  will  readily  be  recognized  by  the 

FIG.  203.  FIG.  204. 


position  of  the  molars.  All  of  the  upper  incisors  are  in  lingual 
occlusion,  while  the  lower  have  been  forced  into  slight  labial  oc- 
clusion. 

The  upper  incisors  were  laced  to  the  expansion  arch  with  wire 


TREATMENT.  213 

ligatures,  and  all  carried  labially  by  tightening  the  nuts  in  front 
of  the  tubes  on  the  anchor  teeth— the  first  molars.  It  will  be  seen 
in  the  next  engraving,  Fig.  204,  that  plain  bands  encircle  the 
lateral  incisors  to  prevent  the  sliding  of  the  ligatures,  while  the 
plain  ligatures  are  used  on  the  centrals.  The  engraving  illustrates 
a  study  model  made  after  completion  of  tooth  movement  and  just 
before  the  appliance  was  removed. 

The  teeth  were  moved  outward  to  correct  positions,  as  shown  in 
the  case  completed,  Fig.  205,  in  just  seven  days.  The  patient  was 
a  boy  sixteen  years  of  age.  The  author  doubts  if  this  could  have 
been  accomplished  so  easily  and  quickly  by  any  other  known 
method.  The  appliance  was  allowed  to  remain  upon  the  teeth  pas- 
sive for  ten  days  before  removal,  when  occlusion  alone  was  de- 
pended upon  for  retention. 

No  effort  was  made  to  change  the  positions  of  the  lower  incisors, 
as  it  was  known  that  the  necessary  change  would  be  effected  by 
occlusion. 

FIG.  205. 


In  the  treatment  of  all  similar  cases  there  is  a  strong  tendency 
on  the  part  of  many  to  perpetuate  a  very  old  fogy  notion  in  apply- 
ing some  form  of  gag  to  keep  the  jaws  apart  and  prevent  the  oc- 
clusion from  interfering  with  the  movement  of  the  teeth.  Such 
practice  should  be  obsolete.  A  good  appliance  will  effect  the 
movement,  regardless  of  the  slight  hindrance  offered  by  occlusion, 
which  is  reduced  to  the  minimum  by  the  patient's  natural  avoid- 
ance of  irritating  the  tender  moving  teeth. 

Fig.  206  represents  the  occlusion  of  the  teeth  of  a  child  nine 


214 


MALOCCLUSION. 


years  of  age.  The  causes  and  peculiarities  of  this  case  were  de- 
scribed in  the  chapter  on  Occlusion.  The  upper  arch  was  widened 
and  the  incisors  moved  labially  by  the  combination  of  jack-screws 
and  section  of  levers  L,  as  in  Fig.  106,  while  the  lower  arch  was 
widened  and  the  incisors  moved  into  correct  position  by  means  of 

FIG.  206. 


FIG.  207. 


E.H.A. 

the  expansion  arch,  as  in  Fig.  193.  Both  upper  and  lower  were 
retained  as  in  Fig.  152.  A  better  plan,  in  the  case  of  the  upper 
arch,  would  have  been  to  place  bands  upon  the  laterals  instead 
of  upon  the  cuspids,  thereby  utilizing  the  reciprocal  force  between 
centrals  and  laterals — their  tendencies  being  to  move  in  opposite 
directions. 

The  completed  case  is  shown  in  Fig.  207. 


TREATMENT.  215 

Fig.  208  shows  the  occlusion  of  the  teeth  of  another  child  who 
had  suffered  the  loss  prematurely  of  a  lower  deciduous  cuspid, 
and  the  same  natural  influences  produced  results  very  similar  to 
those  in  the  last  case.  Treatment  in  all  such  cases  should  be 
immediately  commenced.  The  lower  incisors  should  be  moved 
labially  and  the  full  space  of  the  removed  cuspid  maintained  by 
suitable  devices  until  the  permanent  cuspid  shall  take  its  position  in 
the  arch  to  maintain  its  size,  acting  as  does  a  keystone  in  an  arch 
of  masonry. 

Precisely  the  same  plan  of  retention  was  employed  in  this  case 
as  in  the  last,  with  the  exception  that  as  the  right  lower  cuspid  was 
missing  the  band  was  placed  upon  the  lateral  and  another  spur  at- 
tached to  project  from  its  disto-lingual  angle  and  engage  a  small 
pit  made  in  the  mesial  surface  of  the  deciduous  first  molar,  this 
spur  being  of  sufficient  length  to  maintain  the  full  space  of  the 

FIG.  209. 
FIG.  208. 


missing  cuspid.  The  width  of  the  upper  arch  was  maintained  by  a 
neatly  fitting  vulcanite  plate,  as  in  Fig.  158. 

In  Fig.  209  is  shown  another  case  of  malocclusion  which  is 
represented  from  the  labial  aspect,  while  Fig.  210  shows  the  occlu- 
sal  surfaces  of  both  arches. 

From  the  positions  of  the  mesio-buccal  cusps  of  the  upper  first 
molars  relative  to  the  lower  first  molars  the  case  is  readily  diag- 
nosed as  belonging  to  the  class  of  malocclusion  under  discus- 
sion. 


2l6 


MALOCCLUSION. 


The  patient  was  a  lad  aged  thirteen.  The  strongly  developed 
cuspids  are  erupting  and  have  forced  the  lateral  incisors  lingually 
and  the  centrals  into  torso-occlusion,  while  all  the  lower  incisors, 
though  quite  even,  occupy  positions  lingual  to  normal,  and  the 

FIG.  210. 


cuspids  are  in  torso-occlusion.  From  the  marked  malpositions  of 
the  incisors,  especially  the  left  upper  lateral,  it  would  seem  that 
extraction  in  this  case  would  be  a  necessity,  as  it  would  appear  that 
if  all  the  teeth  were  retained  and  their  crowns  moved  into  the 


TREATMENT. 


217 


line  of  occlusion  they  would  then  occupy  such  inclining  positions 
as  .to  be  unsightly  and  impair  their  functions.  While  this  at  first 
seemed  probable  to  the  author,  he  decided  to  proceed  upon  the  line 

FIG.  211. 


of  retaining  all  of  the  teeth,  enlarging  the  arches  in  all  directions 
sufficiently  for  their  accommodation,  and  to  resort  to  extraction 
only  in  case  of  ultimate  necessity. 

Fig.  211  illustrates  a  study  model,  made  with  the  appliances  in 
position,  and  shows  the  upper  incisors  being  moved  labially  en 


2l8  .          MALOCCLUSION. 

masse  by  means  of  the  expansion  arch,  ligatures,  and  spurred 
bands,  the  spur  and  ligature  acting  upon  the  right  central  to  effect 
the  movement  of  rotation  at  the  same  time.  It  will  be  noted  that 
the  deciduous  second  molar  has  been  removed  and  the  anchor  band 
X  placed  upon  the  first  bicuspid,  not  in  order  to  secure  greater 
anchorage  than  that  which  would  be  offered  by  the  first  permanent 
molar,  but  to  shift  the  tooth  distally  somewhat  in  order  to  gain 
much  needed  space  for  the  cuspid.  The  loosened  temporary  molar 
was  not  removed  and  change  in  the  anchorage  made  until  sufficient 
anchorage  from  the  firm  permanent  molar  with  a  D  band  had  been 
utilized  to  move  'the  incisors  forward  to  nearly  their  correct  posi- 
tions. 

The  arch  was  bent  to  accentuate  the  labio-buccal  movement  of 
the  left  lateral  incisor,  the  force  being  reciprocated  from  the  first 
bicuspid  on  the  left  through  its  attachment  by  the  ligature,  as 
shown. 

The  disto-torso-occlusal  position  of  the  lower  cuspids  shown 
in  this  case  is  the  malposition  most  often  assumed  by  these  teeth, 
not  only  in  this,  but  in  other  classes  of  malocclusion,  and  as  their 
movement  is  unquestionably  one  of  the  most  difficult  to  perform 
they  are  too  often  left  undisturbed.  But  as  we  now  know  that 
there  must  be  complete  harmony  in  the  sizes  of  the  arches  in 
order  to  insure  permanency  of  corrected  occlusion,  and  as  we 
also  know  that  the  lower  arch  is  the  pattern  for  controlling  the 
size  and  form  of  the  upper  arch,  how  important  does  it  appear 
that  these  teeth  shall  be  moved  forward  and  turned  in  their 
sockets  in  all  cases,  that  they  may  do  their  part  in  establishing  the 
full  size  of  the  arch.  The  cuspids  then,  as  they  should,  not  only 
become  as  keystones  in  the  lateral  halves  of  their  own  arch,  but  in  a 
degree  in  those  of  the  upper  arch,  through  occlusal  influence. 
Otherwise  we  must  expect  a  corresponding  diminution  in  the  size 
of  the  upper  arch,  with  a  bunching  of  the  teeth,  through  the  influ- 
ence of  the  lips. 

It  must  be  remembered  that  space  for  their  accommodation  must 
always  be  provided  before  rotation  will  be  possible.  They  must 
therefore  be  carried  forward  until  their  distal  angles  shall  be  free 
from  inlock  with  the  mesial  angles  of  the  first  bicuspids.  To  in- 
sure this  in  this  case  spurs  were  soldered  to  the  arch  to  prevent  the 
ligatures  from  slipping  as  the  nuts  were  tightened,  as  in  Fig.  126. 


TREATMENT. 


219 


In  these  cases  the  author  has  often  used  with  advantage  a  double 
ligature  ahead  of  the  spurs.  In  this  way  the  most  stable  attach- 
ment is  gained  and  a  power  exerted  equal  to  the  direct  application 
of  a  jack-screw.  With  no  other  form  of  ligature  would  it  be  possi- 
ble to  exert  pressure  upon  the  tooth  in  so  effective  a  manner. 

After  the  cuspids  were  moved  forward  sufficiently  to  be  free 
from  the  bicuspids  the  rotation  was  expeditiously  effected  by  occa- 
sional renewal  of  ligatures  in  the  usual  manner,  the  spring  of  the 
arch  being  made  constant  by  wedges  of  rubber  stretched  between 
it  and  the  tooth  bands,  as  properly  shown  in  the  engraving. 

The  author  believes  this  to  be  the  most  powerful  and  practicable 
means  known  for  performing  these  oft-needed  movements.  If 
analyzed  it  will  be  seen  that  the  appliance  is  only  a  series  of  levers, 
made  to  act  in  the  most  effective  manner  on  pure  mechanical 
principles,  combining  reciprocal  and  simple  anchorage,  while  per- 
mitting the  most  perfect  control  over  the  directions  of  movement. 

Fig.  212  shows  the  teeth  after  they  have  been  moved  into  har- 
mony with  the  line  of  occlusion,  the  retaining  devices  in  position. 

By  studying  the  original  positions  of  the  teeth  in  Figs.  209  and 
210,  together  with  their  corrected  positions  in  this  figure,  it  will 
be  seen  that  the  connection  of  the  upper  cuspids  by  bands  and  a 
section  of  G  wire,  as  in  Fig.  152,  not  only  resists  their  torso-labial 
tendency,  but  that  their  infra-occlusal  tendency  is  also  resisted  by 
the  resting  of  the  wire  upon  the  linguo-gingival  ridges  of  the 
laterals,  whose  lingual  tendencies  are  in  turn  resisted  by  the  wire, 
while  their  mesial  tendencies  are  resisted  by  the  centrals.  At  the 
same  time  the  laterals  exercise  resistance  to  the  rotation  of  the 
centrals  by  contact  with  their  disto-fingual  angles,  while  the  mesial 
angles  of  the  centrals  are  prevented  from  moving  labially  by  the 
tension  of  the  fibers  of  the  peridental  membrane,  care  having  been 
exercised  to  preserve  this  tension  by  exerting  force  for  their  proper 
rotation  only  on  their  disto-lingual  angles.  Had  they  been  moved 
labially  before  rotation  there  would  have  been  mesial  disturbance 
of  the  fibers,  instead  of  distal  disturbance  only,  necessitating  their 
retention  by  two  united  bands.  Much  may  often  be  gained  by  an 
intelligent  use  of  the  advantages  offered  by  the  peridental  mem- 
brane. 

The  lower  right  lateral  and  cuspid  were  retained  each  by  a  single 
band  and  spur,  preventing  their  torso-lingual  displacement.  Of 


22O  MALOCCLUSION. 

course  the  same  effect  would  have  resulted  from  the  bands  being 
soldered  together,  with  one  spur  from  the  cuspid  only  bearing 
against  the  buccal  surface  of  the  first  bicuspid,  but  the  difficulty 

FIG.  212. 


of  adjusting  both  bands  at  the  same  time  so  that  one  of  them  would 
not  become  loosened  and  cause  injury  to  the  enamel,  as  they  were 
to  be  worn  in  this  case  for  nearly  two  years,  made  the  plan  ob- 
jectionable. 

There  is  another  decided  advantage  in  the  use  of  spurs  in  all 


TREATMENT.  221 

such  cases,  in  that  the  finer  adjustment  of  the  teeth  may  be  easily 
effected  after  the  application  of  the  retaining  device  by  in  each  in- 
stance stretching  a  piece  of  rubber  between  the  anchor  tooth  and 
spur,  to  create  a  leverage,  and  on  its  subsequent  removal  bending 
back  the  spur  to  hold  the  position.  Figs.  213  and  214  represent 
the  case  three  years  after  treatment.  Attention  is  called  to  the  de- 
velopment to  normal  contour  of  the  alveolus  in  the  region  of  the 
apices  of  the  incisors  which  has  followed  the  establishment  of 
normal  occlusion  and  function  of  the  teeth.  It  will  also  be  noted 

FIG.  213. 


that  the  retention  of  all  of  the  teeth  has  not  caused  undue  promi- 
nence of  the  lips,  which  are  seen  to  be  in  harmony  with  the  other 
lines  of  the  face,  but  that  it  is  a  far  finer  result  than  could  possibly 
have  followed  the  sacrifice  of  one  or  two  teeth  from  each  arch  to 
gain  space. 

Fig.  215  shows  the  left  sides  of  two  models  of  a  case,  before  and 
after  treatment.  The  occlusion  of  the  right  lateral  halves  was  nor- 
mal. On  the  left  (upper  model)  the  lateral  halves  of  both  arches 
were  shortened,  the  upper  permanent  lateral  incisor  being  in  con- 
tact with  the  first  bicuspid.  There  was  a  shrunken  appearance  of 
the  .mouth,  and  the  incisors  were  shifted  from  the  median  line. 
This  condition  was  the  result  of  the  unfortunate  and  unnecessary 


222  MALOCCLUSION. 

loss  of  the  deciduous  upper  cuspid  and  first  and  second  deciduous 
lower  molars. 

What  was  clearly  indicated  was  the  lengthening  of  the  lateral 
halves  of  both  arches  and  the  moving  forward  of  the  centrals,  and 
the  shifting  of  their  positions  to  be  in  harmony  with  the  median 
line. 

FIG.  214. 


This  was  accomplished  in  both  arches  simultaneously  by  means 
of  expansion  arches,  bands,  and  ligatures.  No  bands  were  neces- 
sary on  the  teeth  to  be  moved.  The  incisors  were  laced  to  the  arch 
with  plain  ligatures,  as  in  A,  Fig.  63.  The  spurs  for  preventing  the 
ligatures  on  the  upper  lateral  incisor  and  lower  cuspid  from  slip- 
ping were  placed  well  forward  on  the  arches,  so  that  the  force 
produced  by  tightening  the  nuts  in  front  of  the  anchor  tubes  on  the 
first  molars  exerted  a  direct  mesio-labial  movement  of  these  teeth, 


TREATMENT.  223 

and  as  the  nuts  were  tightened  only  on  the  affected  side  the  lateral 
shifting  of  the  incisors,  as  the  arches  were  lengthened,  was  natural 
and  easy.  See  Figs.  126  and  211. 

The  result  of  treatment  is  shown  in  the  lower  model,  the  sides  of 
the  arches  having  been  sufficiently  lengthened  to  admit  of  the 
eruption  of  the  upper  cuspid  and  lower  bicuspids. 

Retention  was  effected  as  follows :  A  section  of  G  wire  engaged 
R  tubes,  one  of  which  was  soldered  at  its  end  to  the  mesial  surface 
of  a  No.  2  band  on  the  molar  and  the  other  similarly  attached  to  the 

FIG.  215. 


distal  surface  of  a  band  on  the  cuspid.  A  few  pinches  from  the 
regulating  pliers  slightly  lengthened  the  wire,  giving  a  firm  resist- 
ance to  the  distal  tendency  of  the  cuspid,  Fig.  145.  A  similar  de- 
vice, Fig.  146,  was  placed  upon  the  upper  lateral  and  first  bi- 
cuspid. These  were  worn  until  the  eruption  of  the  teeth  made 
their  use  no  longer  necessary.  This  is  a  very  desirable  method  of 
retention  in  all  similar  cases. 

In  the  model  on  the  right  of  the  engraving,  Fig.  216,  is  shown  a 
case  from  which  several  valuable  lessons  may  be  learned,  espe- 
cially by  the  odontocide.  The  case  was  that  of  a  young  lady  aged 
sixteen  years.  Two  years  previous  to  the  making  of  this  model 


224  MALOCCLUS1ON. 

her  teeth  were  practically  faultless  in  occlusion,  and,  with  the  ex- 
ception of  the  first  lo'wer  molar  on  the  left,  of  excellent  structure 
and  color.  At  this  time  the  molar  was  lost  through  neglect  of 
caries,  the  result  being  the  inevitable  tipping  forward  of  the  second 
molar.  The  locking  of  its  inclined  occlusal  planes  with  those  of 
the  upper  second  molar  caused  the  carrying  distally  of  this  side  of 
the  lower  jaw,  and  at  the  same  time  some  forward  movement  of  all 
the  anterior  teeth  of  the  upper  arch,  the  result  being  the  gradual 
shifting  to  nearly  complete  distal  occlusion  of  the  teeth  in  this 
lateral  half  of  the  lower  arch  anterior  to  the  space.  At  the  same 

FIG.  216. 


time  pressure  from  the  upper  lip  was  gradually  molding  the  upper 
arch  to  the  diminishing  size  of  the  lower,  as  shown  by  the  bunch- 
ing tendency  of  the  incisors. 

The  treatment  clearly  indicated  was  lengthening  of  the  lateral 
half  of  the  lower  arch,  the  tipping  to  an  upright  position  of  the 
second  molar,  the  correction  of  the  positions  of  the  teeth  in  the 
upper  arch,  or  the  restoration  of  the  occlusal  planes  to  their  original 
positions. 

The  truing  of  the  positions  of  the  upper  teeth  was  accomplished 
by  means  of  the  expansion  arch,  bands,  and  ligatures,  in  the  usual 
way,  while  the  lengthening  of  the  lateral  half  of  the  lower  arch  was 
accomplished  in  the  same  manner  as  in  the  case  last  described. 
The  tipping  to  an  upright  position  of  the  molar  was  effected  by 
force  exerted  upon  the  nut  in  front  of  the  anchor  tube,  and  also 
by  bending  the  expansion  arch  at  the  point  where  it  entered  the 


TREATMENT.  225 

tube,  so  as  to  give  a  spring  or  pry  upward  on  the  mesial  end  of  the 
tube  and  a  downward  pry  on  its  distal  end.  The  result  is  shown 
in  the  model  of  the  completed  case  on  the  left  of  the  engraving. 
The  patient  was  then  referred  back  to  her  dentist  for  the  insertion 
of  an  artificial  substitute  for  the  lost  molar,  which  being  provided, 
in  the  form  of  a  bridge,  served  the  double  purpose  of  mastication 
and  retention. 

The  requirements  of  orthodontia  and  bridging  are  such  as  should 
induce  a  closer  study  of  their  relations. 

FIG.  217. 


Fig.  217  shows  one  of  the  most  complicated  types  of  cases  be- 
longing to  the  first  class.  Both  lateral  halves  of  the  upper  arch 
are  in  lingual  occlusion,  thus  greatly  encroaching  upon  its  incisive 
region  and  forcing  the  laterals  into  marked  torso-lingual  occlu- 
sion and  the  centrals  into  torso-labial  occlusion. 

The  result  of  the  occlusion  of  the  buccal  cusps  of  the  upper 
molars  and  bicuspids  with  the  lingual  cusps  of  their  opposing  teeth, 
as  shown  in  the  dotted  lines  in  Fig.  219,  is  a  tendency  to  force  the 
apices  of  the  roots  of  the  lower  molars  and  bicuspids  farther  and 
farther  buccally,  with  the  opposite  effect  on  the  corresponding 
upper  teeth.  Such  a  result  was  most  noticeable  in  this  case,  both 
in  the  inclinal  angles  of  the  teeth  and  in  the  facial  lines,  the  middle 
part  of  the  face  being  narrowed,  while  the  lower  part  was  broad- 
ened and  puffy,  the  condition  being  really  a  distortion  of  otherwise 
comely  features. 

16 


226  MALOCCLUSION. 

The  line  of  treatment  was  toward  the  ideal,  the  widening  of  the 
upper  arch,  the  correcting  of  the  malpositions  of  the  incisors,  and 
the  narrowing  of  the  lower  arch. 

Fig.  218  shows  the  upper  arch  being  widened  by  means  of  the 
expansion  arch,  adjusted  in  the  usual  way  and  reinforced  by  one  of 
the  spring  levers  L,  all  as  shown  and  described  in  the  chapter  on 
Combinations  of  the  Expansion  Arch.  The  incisors  were  moved 
forward  en  masse  and  rotated  by  means  of  spurred  bands,  ligatures, 
etc.,  after  the  usual  method. 

FIG.  218. 


The  narrowing  of  the  lower  arch  was  effected  by  means  of  a 
device  manufactured  for  the  occasion,  and  is  the  only  instance  in 
the  author's  experience  where  an  appliance  differing  from  those 
standard  forms  described  throughout  this  book  has  been  required. 
The  standard  appliances  might  have  been  used  to  accomplish 
even  this  movement,  but  their  use  would  have  required  a  longer 
time. 

The  device  consisted  of  a  piece  of  Stubb's  steel  wire  slightly 
less  than  one-eighth  of  an  inch  in  diameter,  bent  closely  to  con- 
form to  the  shape  of  the  arch,  the  temper  being  so  soft  as  to  make 
this  easy  of  accomplishment.  The  extreme  ends  were  bent 
sharply  at  right  angles  and  filed  to  the  sharpest  hook-like  points, 
which  were  made  to  engage  the  buccal  pits  on  the  first  molars,  as 
in  Fig.  219.  If  the  points  are  bent  at  the  proper  angle  and  made 
extremely  sharp  no  drilling  of  cavities  in  the  enamel  is  necessary, 


TREATMENT. 

but  they  will  readily  remain  in  position  when  grasping  the  sides  of 
the  tooth  at  any  point,  especially  just  beneath  the  gingival  ridge. 

After  the  wire  arch  had  been  tested  and  found  to  be  of  exactly 
the  length  and  shape  necessary,  the  ends  were  sprung  closer  to- 
gether, or  made  to  conform  in  shape  to  an  ideal  arch.  It  was  then 
tempered  to  extreme  hardness,  after  which  it  was  polished  and 
given  a  spring  temper  by  being  held  in  contact  with  a  sheet  of  thin 
metal  over  a  flame  until  its  color  had  changed  to  a  light  blue.  It 
was  sprung  into  position  and  the  amount  of  force  exerted  upon  the 
teeth  was  found  to  be  about  twenty  pounds,  but  being  so  evenly 

FIG.  219. 


distributed  little  inconvenience  was  experienced  by  the  patient  and, 
somewhat  to  our  surprise,  the  dental  arch  was  molded  into  correct 
shape  by  bending  of  the  alveolus  in  the  short  period  of  eleven 
days.  After  the  spring  of  the  arch  had  been  expended  it  was  al- 
lowed to  remain  as  a  retaining  device  for  two  or  three  weeks,  held 
in  position  by  an  occasional  ligature  of  the  brass  wire. 

It  might  be  asked  why  a  section  of  heavy  piano-wire  would  not 
answer  the  same  purpose.  The  most  important  reason  is  that  the 
fibers  infolded  in  the  bending  have  little  contractile  power,  its  use- 
fulness as  a  spring  being  confined  to  its  expansion  or  outward  ac- 
tion. Another  reason  is  that  it  is  not  sufficiently  heavy.  It  is 
always  important  that  the  wire  be  tempered  after  it  has  been  bent 
to  the  desired  form. 


228 


MALO^CLUSION. 


Fig.  220  shows  the  upper  arch  completed  and  the  retaining  de- 
vices in  position,  while  Fig.  221  shows  both  arches  completed  and 
the  teeth  in  occlusion.  The  lingual  tendency  of  the  upper  incisors 

FIG.  220. 


FIG.  221. 


and  the  torso-  and  infra-occlusal  tendencies  of  the  upper  cuspids,  as 
well  as  the  lingual  tendency  of  the  molars  and  bicuspids,  were 
resisted  by  double  bands  connected  by  a  section  of  the  wire  G  and  a 
vulcanite  plate,  as  illustrated.  The  bands  upon  the  cuspids  are 
also  shown  in  Fig.  221. 

The  model  illustrated  in  Fig.  222  represents  a  case  where  one 


TREATMENT. 


229 


only  of  the  lateral  halves  of  the  upper  arch  was  in  lingual  occlu- 
sion, while  the  lateral  incisors  were  in  marked  torso-lingual  oc- 
clusion. The  patient  was  a  child  eight  years  old,  the  deciduous 
molars  and  cuspids  being  still  in  position. 

The  plan  of  treatment  clearly  indicated  was  widening  the  arch 
by  movement  buccally  of  the  affected  side  only,  with  labial  move- 
ment of  centrals  and  torso-labial  movement  of  laterals.  Fig.  223 

FIG.  222. 


FIG.  223. 


shows  a  view  of  this  arch  from  the  occlusal  aspect,  with  the  appli- 
ances for  accomplishing  these  movements  of  the  teeth  in  position. 
It  will  be  seen  that  all  of  the  teeth  on  the  left  side  are  used  as 
anchorage  and  their  combined  resistance  concentrated  through  the 
force  distributed  by  the  external  and  internal  arches  upon  the  left 
first  permanent  molar.  But  a  few  days  were  necessary  to  move  this 
tooth  into  correct  position.  A  wire  ligature  was  then  made  to 
encircle  the  second  deciduous  molar  and  the  expansion  arch,  thus 
practically  transferring  the  force  to  this  tooth.  Later  the  first 


230  MALOCCLUSION. 

deciduous  molar  was  moved  out  in  the  same  way.  The  object  of 
moving  the  teeth  one  at  a  time  was  to  avoid  overtaxing  the  anchor- 
age derived  from  the  opposite  side  of  the  arch.  Had  the  effort 
been  made  to  move  all  at  the  same  time  it  is  probable  that  the  nor- 
mal side  would  have  been  displaced  more  rapidly  than  the  ab- 
normal, on  account  of  the  increased  resistance  offered  by  the 
inlocking  of  the  inclined  planes  of  the  cusps  of  the  molars  on  the 
abnormal  side. 

While  the  appliances  were  acting  upon  the  lateral  half  of  the 
arch  the  lateral  incisors  were  carried  forward  and  rotated  by  bands, 
spurs,  and  ligatures,  with  spurs  on  the  expansion  arch  to  prevent 
slipping,  further  assisted  by  the  tightening  of  the  nuts  on  the  ex- 
pansion arch,  as  in  the  case  last  described. 

By  studying  the  positions  of  the  teeth  in  the  upper  arch  it  will 
be  seen  that  their  tendencies  were  similar  to  those  in  the  last  case, 
and  that  they  were  overcome  in  a  similar  manner  and  by  the  same 
combinations  of  bands  and  spurs.  The  widened  arch  was  retained 
by  the  vulcanite  plate,  Fig.  158. 

The  mesial,  torsional,  and  lingual  tendencies  of  the  right  lateral 
and  the  lingual  tendencies  of  the  other  incisors  were  resisted  by 
bands  upon  the  laterals  connected  by  a  piece  of  G  wire  soldered 
to  their  lingual  surfaces. 

FIG.  224. 


Fig.  224  shows  a  case  belonging  to  this  class  in  which  there 
was  marked  lingual  inclination  of  both  upper  and  lower  incisors, 
as  well  as  of  lower  bicuspids,  the  latter  occluding  wholly  inside  of 
their  upper  antagonists,  which  were  thus  inclined  labially.  Figs. 
225  and  226  show  both  arches  from  the  occlusal  aspect.  The  ex- 
pansion arch  and  ligature  attachments  are  shown  in  position  on 


TREATMENT. 


231 


the  lower  arch,  which  is  to  be  enlarged  by  the  renewal  or  twisting 
of  the  ligatures  and  the  tightening  of  the  nuts.  The  spurred  band, 
ligature,  and  rubber  wedge  are  shown  on  the  right  cuspid  for  ef- 
fecting its  rotation. 

There  are  two  points  of  interest  in  connection  with  the  upper 
arch  which  have  not  been  brought  out  in  any  of  the  similar  cases 
described  previously.  The  first  is  the  prominence  of  the  right 
cuspid,  and  the  second  is  the  torsal  position  of  the  left  first  molar. 
The  rotation  of  the  molar  and  reduction  of  the  cuspid  were  accom- 
plished while  the  incisors  were  being  carried  forward,  by  bending 
and  so  adjusting  the  arch  that  it  would  bear  with  considerable  force 


FIG.  225. 


FIG.  226. 


against  the  prominent  cuspid.  The  force  was  increased  by  a 
strip  of  rubber  drawn  between  the  tooth  and  arch.  At  the  same 
time  the  ligatures  encircling  the  bicuspids  on  that  side  and  the 
incisors  in  front  exercised  a  reciprocal  force  upon  it.  The  molar 
was  rotated  by  the  bending  of  the  expansion  arch  at  a  point  just 
mesial  to  the  nut  so  as  to  exert  force  buccally  upon  the  mesial 
end  of  the  tube  and  lingually  upon  the  distal  end,  this  being  as- 
sisted by  the  reciprocal  force  from  the  incisors  as  the  nut  was  tight- 
ened to  carry  them  forward.  It  was  necessary  to  occasionally 
remove  the  arch  and  increase  the  tension  by  slightly  reducing  the 
bend  at  the  point  near  the  nut. 

Fig.  227  shows  the  lower  arch  nearing  completion,  and  Fig.  228 
shows  the  method  of  retention. 

A  gold  crown  already  on  the  first  molar  was  utilized  for  reten- 


232 


MALOCCLUSION. 


tion  by  making  a  small  hole  in  the  mesio-lingual  angle  and  insert- 
ing one  end  of  a  section  of  wire  G,  the  other  end  being  engaged 
with  a  tube  R  soldered  to  the  disto-lingual  angle  of  a  cuspid 
band.  This  effectually  resisted  the  lingual  tendency  of  the  bicus- 
pids. The  lingual  tendency  of  the  cuspid  on  the  opposite  side  was 

FIG.  227. 


FIG.  228. 


resisted  in  the  same  manner,  only  that  a  pit  was  made  in  the  enamel 
of  the  molar  and  afterward  suitably  filled. 

The  twisted  ends  of  the  ligatures  are  improperly  shown  in  the 
illustrations  of  this  case.  They  should  be  as  in  Fig.  63. 

Fig.  229  shows  a  case  in  which  there  is  much  space  between  the 
occlusal  edges  of  the  incisors,  the  result  of  the  habit  of  holding 
the  tongue  between  the  teeth.  It  also  shows  the  method  of  cor- 
recting the  infra-occlusion  of  the  incisors  by  means  of  the  expan- 


TREATMENT. 


233 


sion  arch.  The  middle  of  each  side  of  the  arch  was  made  to  bear 
against  a  spur  soldered  to  a  band  on  the  cuspid,  which  acted  as  a 
fulcrum,  the  center  of  the  arch  being  sprung  over  hooklike  spurs 
projecting  from  the  labial  surfaces  of  bands  on  the  incisors  and  its 
spring  thus  exerting  a  down-ward  force  upon  them.  The  use  of 
ligatures  instead  of  spurred  bands  for  the  incisors,  as  represented 
in  Fig.  193,  is  now  preferred.  Either  of  the  arches,  E  or  B,  may 
be  used. 

FIG.  229. 


FIG.  230. 


This  is  an  excellent  method  of  correcting  infra-occlusion  of  teeth, 
and  yet  it  must  not  be  forgotten  that  the  force  also  tends  to  elevate 
the  anchor  teeth  and  that  they  must  not  be  overtaxed  by  the  at- 
tempt to  move  too  many  teeth  at  once.  Not  more  than  one  or  two 
should  be  moved  at  a  time.  If  pronounced  vertical  movement  of 
the  anchor  teeth  should  occur,  the  bands  should  be  shifted  to  other 
molars.  It  is  often  desirable  in  these  cases  to  reinforce  the  molars 
by  occlusal  anchorage,  by  means  of  bands  and  buttons  on  the 
lower  incisors,  or  by  attachment  to  lower  cuspids,  as  in  Fig.  230, 
which  are  made  to  engage  rubber  ligatures  stretched  over  spurs 
on  the  arch  or  on  bands  on  the  upper  teeth. 


234  MALOCCLUSION. 

The  best  means  of  retaining  teeth  so  elevated  is  to  allow  the  arch 
to  remain  in  position  the  requisite  time. 


CHAPTER    XVIII. 

TREATMENT  OF   CASES. CLASS   II,   DIVISION    I. 

IT  will  be  remembered  that  the  distinguishing  characteristics  of 
cases  belonging  to  this  class  and  divisions  are  distal  occlusion  of 
both  lateral  halves  of  the  lower  arch,  sub-development  of  the  lower 
maxilla,  narrowed  upper  arch,  lengthened  and  protruding  upper 
incisors,  and  lengthened  lower  incisors.  It  will  also  be  remem- 
bered that  these  patients  are  in  almost  every  instance  affected 
with  some  form  of  nasal  obstruction,  necessitating  mouth-breath- 
ing, which  usually  begins  at  an  early  age,  causing  the  mouth  to  be 
held  open  almost  constantly  and  the  lips  and  buccal  muscles  to 
act  abnormally.  The  upper  lip  is  drawn  upward  in  the  effort  at 
breathing  and  fails  to  develop  in  size  and  function,  exercising  little, 
if  any,  restraint  upon  the  labial  movement  of  the  incisors.  Their 
protrusion  thus  becomes  more  and  more  pronounced,  partially  as  a 
result  of  pressure  from  the  tongue  and  narrowing  of  the  arch,  but 
principally  because  the  lower  lip  is  so  frequently  forced  against 
their  lingual  surfaces  in  swallowing  and  in  the  effort  at  moistening 
the  mucous  membrane  of  the  mouth.  Both  upper  and  lower  in- 
cisors become  lengthened,  probably  from  lack  of  function,  so  that 
the  occlusal  edges  of  the  lower  are  frequently  in  contact  with  the 
mucous  membrane  of  the  hard  palate. 

It  is  a  common  mistake  to  suppose  that  this  form  of  malocclu- 
sion  is  the  result  of  overdevelopment  of  the  upper  jaw.  The 
author  has  never  seen  a  case  where  it  seemed  to  him  that  this  con- 
dition really  existed.  The  marred  facial  lines  and  the  condition 
of  the  upper  jaw  and  teeth  are  but  the  natural  results  of  distal 
occlusion,  recession  of  the  lower  jaw,  and  the  consequent  modified 
functions  of  the  lips  and  cheeks.  If  it  were  possible,  in  the  case  of 
any  person  with  normal  features  and  teeth  in  normal  occlusion, 
to  force  the  lower  jaw  back  until  the  teeth  were  in  distal  occlusion, 


TREATMENT    OF    CASES.— CLASS    II,    DIVISION    I.  235 

narrow  the  upper  arch,  compel  mouth-breathing,  move  forward 
and  slightly  lengthen  the  upper  incisors  and  cuspids,  and  shorten 
the  upper  lip,  we  would  then  have  a  typical  case  of  this  class 
of  deformities.  It  seems  quite  probable  that  all  of  these  conditions 
have  been  gradually  brought  about  as  a  result  of  mouth-breathing, 
at  least  in  a  very  large  percentage  of  cases.  It  therefore  becomes 
apparent  that  treatment  should  be  first  directed  toward  the  restora- 
tion of  normal  breathing,  and  it  is  now  the  belief  of  the  author,  after 
much  experience  with  these  cases,  that  failure  in  maintaining  cor- 
rected occlusion  will  sooner  or  later  follow  unless  normal  respira- 
tion be  established.  Treatment  of  the  occlusion  without  attention 
to  the  nasal  tract  is  but  the  treatment  of  symptoms  without  removal 
of  the  cause.  For  that  reason  the  advice  and  co-operation  of  a 
competent  rhinologist  should  early  be  enlisted  in  order  that  both 
lines  of  treatment  may  progress  simultaneously,  yet  we  are  much 
at  the  mercy  of  the  rhinologist  for  the  success  of  our  efforts. 

Treatment. — There  are  two  distinct  lines  of  treatment  which  may 
be  followed.  The  first  has  for  its  object  merely  the  improvement 
of  the  occlusion  and  restoration  of  harmony  in  the  sizes  of  the 
arches.  The  second  is  toward  the  ideal, — the  establishment  of  nor- 
mal occlusion  and  harmony  in  the  relation  of  the  jaws  and  facial 
lines. 

In  following  the  first  plan  of  treatment,  in  order  to  establish 
harmony  in  the  sizes  of  the  arches  and  improve  the  occlusion,  one 
bicuspid  (preferably  the  first)  from  each  lateral  half  of  the  upper 
arch  must  be  sacrificed  and  the  arch  shortened  by  moving  distally 
the  incisors  and  cuspids  until  the  space  be  closed.  The  incisors 
also,  in  many  instances,  require  to  be  depressed  in 'their  sockets. 
No  effort  is  made  to  change  the  mesio-distal  relation  of  the  jaws, 
or  the  occlusion  posterior  to  the  space. 

So  much  force  is  necessary  to  move  the  incisors  and  cuspids 
back  to  their  correct  positions  and  depress  them  in  their  sockets, 
as  well,  that  it  is  impossible  by  any  known  form  of  appliance  to  gain 
sufficient  anchorage  from  the  remaining  teeth  'without  effecting 
their  serious  displacement.  Notwithstanding  this  fact  the  effort  . 
is  frequently  made  to  accomplish  these  movements  by  this  means 
of  anchorage,  most  of  the  appliances  which  have  been  devised  for 
the  treatment  of  this  class  of  cases  depending  on  simple  anchorage 
from  the  molars.  It  would  seem  that  only  a  slight  familiarity  with 


236  MALOCCLUSION. 

the  anatomy  of  the  parts  would  readily  convince  any  thoughtful 
person  of  the  uselessness  of  such  attempts.  Let  the  reader  study 
the  engraving,  Fig.  34,  and  note  the  comparative  shortness  of  the 
roots  of  the  molars  (upper),  and  the  normal  mesial  inclination  of 
their  crowns,  remembering  their  natural  tendency  to  mesial 
movement.  Consider,  also,  the  very  cancellous  structure  of  the 
alveolus.  Compare  these  conditions  with  those  of  the  cuspids  and 
incisors — their  long  roots,  the  firm  resistance  offered  by  the  bank 
of  bone  on  their  lingual  surfaces,  and  the  fact  that  in  all  cases  of 
protrusion  their  pronounced  inclination  so  braces  them  in  their 

FIG.  231. 


positions  as  to  enormously  increase  their  resistance  to  movement. 
Then  if  he  consider  the  fact  that  the  principles  of  occlusion  neces- 
sitate our  guarding  with  zealous  care  the  relations  of  the  occlusal 
planes  of  the  molars  he  will,  we  believe,  agree  that  it  is  the  merest 
folly  to  depend  upon  simple  anchorage  from  the  molars  in  the 
hope  to  effect  the  complete  distal  movement  of  the  incisors  and 
cuspids.  Practice  abundantly  confirms  this  theory.  We  must 
therefore  resort  to  occipital  anchorage  in  connection  with  the  arch 
B,  bands  D,  traction  bar  A,  and  heavy  elastic  bands,  adjusted  as 
described  in  general  description  of  author's  appliances.  Figs.  231 
and  232  show  the  appliances  in  position. 

Before  adjusting  the  arch  B  it  is  made  to  conform  to  the  shape 
of  the  ideal  arch,  or  as  we  wish  the  teeth  to  be  finally  arranged ;  and 


TREATMENT   OF    CASES. CLASS    II,    DIVISION    I. 


237 


as  it  is  carried  distally,  even  though  the  teeth  be  irregular  they  are 
forced  to  gradually  conform  to  its  shape, — an  advantage  over  every 

FIG.  232. 


other  similar  device  for  the  purpose.  The  common  method  has 
been  to  rigidly  attach  the  traction  bar,  or  its  equivalent,  to  a  swaged 
or  vulcanite  cap  covering  and  firmly  resting  against  all  the  teeth 


238 


MALOCCLUSION. 


to  be  moved,  and  thus  their  relative  positions  could  not  be  changed 
in  the  movement. 

For  support  the  front  of  the  arch  may  be  allowed  to  rest  in 
notches  formed  in  the  united  ends  of  the  bands  on  the  incisors,  as 
in  C,  Fig.  233,  or  in  notches  filed  in  pieces  of  the  wire  G  soldered 
at  right  angles  to  the  labial  surfaces  of  the  bands,  as  in  Fig.  234 


FIG.  233. 


FIG.  234. 


and  B,  Fig.  233,  or  against  short  spurs  of  the  wire  G  soldered  to 
the  labial  surface  of  the  band  near  its  upper  edge  and  at  right 
angles  to  the  long  axis  of  the  tooth,  as  in  A,  Fig.  233.  The  latter 
is  the  author's  favorite  method,  as  it  presents  a  neater  appearance 
and  effectually  prevents  the  arch  from  sliding  against  the  gum — 
the  only  direction,  in  reality,  toward  which  it  tends. 

The  small  ligatures  shown  on  the  side  of  the  arch,  for  automatic 
retention,  exert  a  constant  gentle  traction  and  prevent  the  incisors 
from  springing  back  at  times  when  the  head-gear  is  not  worn. 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    I.  239 

These  ligatures  should  be  delicate,  and  made  as  described  under 
general  description  of  ligatures.  They  are  best  applied  as  follows : 
First  tie  a  silk  ligature  of  generous  length  firmly  around  the  arch 
in  front  of  one  of  the  little  fixed  collars.  One  of  the  ends  is  then 
slipped  through  the  rubber  ligature,  which  with  a  pair  of  delicate 
pliers  is  carried  back  and  slipped  over  the  end  of  the  tube  on  the 
anchor  band  D.  The  strand  of  silk  is  then  drawn  forward  until 
the  desired  tension  upon  the  rubber  is  gained,  when  the  ends  are 
tied  in  a  surgeon's  knot,  followed  by  a  plain  knot,  and  cut  off  as 
shown  in  the  engraving.  It  is  a  mistake  to  use  other  than  very  . 
delicate  rubber  ligatures,  as  some  will  persist  in  doing  in  the  belief 
that  it  expedites  tooth  movement  and  assists  the  head-gear.  The 
only  effect  is  to  drag  forward  the  molars  and  bicuspids  and  en- 
danger the  relations  of  their  occlusal  planes,  which  cannot  be  too 
carefully  guarded.  Very  often  the  author  uses  no  ligatures,  espe- 
cially where  any  lateral  spring  is  given  to  the  arch.  Its  tendency 
then  being  to  slide  distally  through  the  tubes,  it  will  be  adequate 
for  temporary  retention. 

The  arch  should  not  be  bent  so  as  to  give  it  too  much  lateral 
spring.  The  author  has  known  embarrassing  results  where  dentists 
have  applied  it  with  full  lateral  spring  and  allowed  it  to  be  worn 
for  several  weeks  without  modification,  much  buccal  displacement 
of  the  molars  being  caused.  It  must  be  remembered  that  the 
molars  in  this  case  are  not,  properly  speaking,  anchor  teeth,  the 
office  of  the  D  bands  being  merely  to  passively  support  the  ends 
of  the  arch,  which  should  be  so  placed  and  bent  that  very  little 
pressure  need  be  brought  to  bear  upon  them.  The  dental  arch 
needs  to  be  widened  principally  in  the  region  of  the  cuspids,  and 
this  is  usually  accomplished  as  they  are  carried  distally,  by  the  di- 
rection of  force  through  the  centrals  and  laterals.  Indeed,  this 
tendency  must  sometimes  be  modified  by  bending  the  arch  to  bear 
against  their  labial  surfaces.  Occasionally  there  is  a  tendency  of 
the  centrals  to  slide  behind  the  laterals,  or  of  the  cuspids  to  rotate, 
owing  to  the  triangular  shape  of  their  roots  and  the  angle  at 
which  they  receive  the  transmitted  force.  All  such  unfavorable 
tendencies  can  be  easily  overcome  by  compelling  their  correct 
relation  with  the  arch,  by  bands,  spurs,  and  ligatures  placed  at 
points  best  calculated  to  antagonize  their  tendencies.  Usually  the 
wire  ligatures  alone  are  ample. 


24O  MALOCCLUSION. 

The  various  parts  of  this  appliance  should  be  added  at  different 
times,  that  the  patient  may  become  gradually  accustomed  to  them. 

The  head-gear  proper  has  been  greatly  improved.  It  is  shown 
in  correct  adjustment  in  Fig.  232,  although  the  position  should  be 
higher  or  lower  on  the  back  of  the  head  according  to  the  require- 
ments for  the  direction  of  force.  A  mistake  is  frequently  made 
in  having  the  head-gear  worn  too  high  on  the  head,  the  result 
being  to  shorten  the  teeth  too  much  and  limit  the  retraction  force. 
If  much  shortening  of  the  teeth  be  desired,  it  should  be  worn  some- 
what higher  than  indicated  in  the  engraving. 

The  rim  should  be  adjusted  to  the  proper  size,  and  be  modified 
in  form  by  slightly  bending  to  fit  the  head.  It  should  be  in  all 
parts  of  its  circumference  at  least  one-fourth  inch  from  the  head. 
One  of  the  recent  improvements  is  the  form  given  the  rim  in  the 
region  of  the  neck,  it  being  made  to  bow  outward  to  avoid  pres- 
sure. Another  improvement  is  that  immovable  collars  have  been 
placed  upon  the  rim,  to  prevent  the  sliding  of  the  elastic  bands 
toward  each  other. 

After  the  head-gear  has  been  worn  for  some  time  the  netting  be- 
comes stretched,  and  necessitates  the  taking  up  of  the  slack  by  the 
lacing  cord  which  connects  it  with  the  rim.  The  great  advantage 
of  this  head-cap  is  that  the  rim  receives  the  force  and  distributes 
it  equally  over  the  back  of  the  head,  thus  avoiding  headache,  a 
common  result  in  the  use  of  all  other  styles  because  of  interference 
with  the  circulation  by  localized  pressure.  Thus  there  may  be 
from  two  to  three  times  the  ordinary  degree  of  pressure,  and  con- 
sequently much  shortening  of  the  time  of  treatment. 

Three  heavy  elastic  rubber  bands*  are  shown  looped  to  the  side  of 
the  rim  of  the  cap,  the  one  in  the  center  not  in  use,  but  in  readiness. 
As  the  others  become  somewhat  weakened  by  stretching,  the  center 
one  is  to  be  stretched  forward  and  made  to  engage  the  end  of 
the  traction  bar  also.  It  is  well  to  have  one  or  more  of  these 
bands  always  in  readiness,  and  the  patient  should  be  induced  to 
wear  the  head-gear  as  much  of  the  time  as  possible  with  good 
firm  tension,  that  the  work  may  be  done  expeditiously.  A 
tedious,  protracted  operation  is  unnecessary  and  should  be 
avoided.  Patients  and  parents  should  be  impressed  with  the  fact 
that  treatment  is  in  progress  only  while  the  head-gear  is  worn,  and 

*Johann  Faber's  oo^  and  ooojHj  are  best  suited. 


TREATMENT   OF    CASES. — CLASS    II,   DIVISION    I.  24! 

that  every  hour  of  omission  will  prolong  the  operation  propor- 
tionately. The  author  has  noticed  a  marked  difference  in  the 
progress  of  treatment  in  case  of  patients  who  come  from  a  dis- 
tance and  make  the  wearing  of  the  head-gear  their  chief  purpose, 
in  comparison  with  the  progress  in  case  of  patients  who  greatly 
limit  the  time  of  wearing  it  on  account  of  social  and  other  duties. 

The  operator  should  carefully  inspect  ligatures  and  attachments 
twice  a  week,  see  the  patient  adjust  the  head-gear,  and  test  the 
amount  of  force  exerted  upon  the  moving  teeth,  which  latter  can  be 
easily  done  with  a  delicate  spring  scale  (such  as  trout-fishermen 
use,  and  which  costs  about  thirty-five  cents),  by  engaging  the  hook 
in  the  center  of  the  traction  bar  and  exerting  tension  upon  the 
handle  until  the  exact  force  is  registered.  The  amount  of  force 
which  seems  to  be  comfortably  tolerated  by  patients  varies  from 
four  pounds  to  thirteen,  although  only  the  gentlest  pressure  should 
be  applied  in  the  beginning.  It  may  be  gradually  increased  as 
the  patient  shall  become  accustomed  to  wearing  the  appliances. 
Very  light  tension  is  given  to  the  elastics  by  extending  their  length 
by  loops  of  suitable  cord,  as  shown  in  the  engraving.  After  the 
patient  shall  have  become  accustomed  to  wearing  the  head-gear 
the  loops  should  be  dispensed  with,  the  rubbers  being  stretched 
forward  and  made  to  engage  the  hooks  on  the  ends  of  the  traction 
bar. 

As  it  is  desirable  to  hasten  the  treatment  of  these  cases  as  much 
as  is  consistent  with  the  physiology  of  tooth  movement,  the  author 
has  found  a  combination  of  the  traction  screw  with  the  arch  B, 
as  shown  in  Fig.  235,  a  decided  advantage,  especially  with  pa- 
tients over  the  age  of  fifteen  years. 

It  will  be  seen  that  the  cuspid  teeth  are  being  retracted  in  ad- 
vance of  and  independent  to  the  moving  incisors,  by  means  of  the 
traction  screws.  These  should  be  adjusted  first  and  operated  in 
the  usual  way  for  performing  retraction  of  the  cuspids,  as  per 
directions  in  Combinations  of  the  Traction  Screw.  The  ends  of 
the  arch  B  are  supported  by  passing  them  through  tubes  D 
previously  soldered  near  the  mesial  end  of  the  sheath  Y  of  the  trac- 
tion screw,  as  when  in  combination  with  the  expansion  arch. 

The  delicate  ligatures  shown  in  Fig.  231  are  omitted  from  Fig. 
235  in  order  that  the  more  important  lines  may  not  be  obscured. 
The  should  of  course  be  attached  to  the  arch  in  the  usual  way,  and 


242  MALOCCLUSION. 

be  made  to  engage  the  sheaths  on  the  anchor  bands.  In  the  en- 
graving one  of  the  traction  screws  is  represented  as  being  operated 
on  the  lingual  side  of  the  dental  arch.  This  is  rarely  advisable,  for 
reasons  previously  stated.  The  better  position  is  on  the  buccal 
side  of  the  dental  arch,  as  shown  on  the  opposite  side  of  the  en- 
graving. 

If  the  traction  screws  be  adjusted  and  operated  with  the  care 
always  so  necessary  in  retraction  of  the  cuspids,  the  result  of  their 
use  in  this  combination  will  be  most  gratifying,  as  the  advantages 


FIG.  235. 


—2 


of  stationary  and  occipital  anchorage  will  be  combined,  the  result 
being,  if  intelligently  managed,  to  greatly  lessen  the  time  of  treat- 
ment. It  may  be  further  lessened  by  the  surgical  removal  of  bone 
in  advance  of  the  teeth  to  be  moved,  as  elsewhere  described.  Al- 
together we  diminish  the  time  required  by  the  old-style  apparatus 
about  two-thirds,  and  that,  too,  with  complete  movement  of  the 
anterior  teeth  and  no  displacement  of  the  molars. 

Fig.  236  shows  the  models  of  the  case  shown  in  Fig.  235  at  the 
periods  of  beginning  and  completion  of  treatment.  As  there  is 
such  remarkable  similarity  in  all  these  cases,  the  difference  being 
almost  wholly  in  degree  and  the  requirements  in  the  treatment  ac- 
cording to  this  plan  so  unvarying,  the  further  illustration  of  cases 
seems  to  the  author  unnecessary.  It  should  be  remembered  that 


TREATMENT   OF    CASES. — CLASS    II,   DIVISION    I. 


243 


this  plan  of  treatment,  although  perhaps  the  only  practicable  one 
in  a  large  percentage  of  cases,  has  one  serious  objection,  in  that 
the  abnormal  mesio-distal  relations  of  the  jaws  are  not  changed, 
and  while  harmony  in  the  sizes  of  the  dental  arches  is  established, 
yet  in  reality  we  but  modify  one  deformity  by  creating  another. 
The  resultant  effect  upon  the  facial  lines  is  sometimes  very  marked, 
but  varies  according  to  the  original  relations  of  the  features  with 
the  line  of  harmony,  principally  according  to  the  degree  of  devel- 
opment of  the  mental  prominence.  The  difference  in  the  effect 
on  the  facial  lines  from  following  this  plan  of  treatment  is  shown 

FIG.  236. 


in  the  two  profiles,  Figs.  237  and  238.  Fig.  238  shows  the  facial 
lines  after  treatment  of  the  cases  illustrated  in  Figs.  235  and  236. 

In  the  treatment  of  all  cases  belonging  to  Class  II  the  im- 
portance of  correct  adjustment  of  the  teeth  in  the  lower  arch  must 
not  be  ignored.  Usually  the  size  of  the  arch  and  arrangement  of 
the  teeth,  with  the  exception  of  the  lengthened  incisors,  is  quite 
normal,  and  yet  in  a  very  large  percentage  of  cases  it  will  be  found 
that  there  is  lingual  displacement  of  the  incisors,  especially  of  the 
laterals,  often  accompanied  by  torso-occlusion  of  the  cuspids.  We 
have  already  pointed  out  the  importance  of  in  all  cases  establishing 
the  normal  relations  of  these  teeth  with  their  lines  of  occlusion. 

It  is  nearly  always  desirable  in  these  cases  to  shorten  the  lower 
incisors  about  one-sixteenth  inch  by  grinding.  This  will  in  no 
way  injure  them,  but  should  never  be  resorted  to  until  after 


244 


MALOCCLUSION. 


their  correct  adjustment  shall  have  been  accomplished  and  they 
shall  have  been  allowed  to  settle  in  their  sockets  for  at  least  two 
weeks.  The  movement  of  these  teeth  into  their  correct  positions 
is  of  course  accomplished  by  the  expansion  arch  E,  spurs,  and 
wire  ligatures,  all  as  described  in  the  treatment  of  cases  belonging 
to  the  first  class  of  malocclusion. 


FIG.  237. 


Not  only  are  the  incisors  found  to  occupy  positions  of  supra- 
occlusion,  but  the  bicuspids  and  even  the  first  molars  are  occa- 
sionally found  in  marked  infra-occlusion,  probably  due  to  -arrested 
development  of  their  alveoli.  The  effect  is  to  shorten  the  bite  and 
greatly  intensify  the  protrusion  of  the  upper  incisors.  In  such 
cases  the  elevation  of  the  bicuspids  and  first  molars  is  necessary. 

Fig.  239  shows  how  it  may  be  accomplished  from  the  spring  of 
the  expansion  arch.  (Either  the  E  or  B  Arch  may  be  used). 
Elevating  force  is  acquired  by  springing  the  arch  under  spurs 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    I. 


245 


soldered  to  bands  cemented  to  the  bicuspids,  resistance  in  the  oppo- 
site direction  being  gained  by  bands  and  spurs  on  the  incisors  and 
tubes  attached  to  clamp  bands  No.  2  on  the  second  or  third  molars.* 
Another  method  of  securing  the  ends  of  the  arch  is  now  preferred. 
After  drawing  their  temper  the  ends  are  bent  carefully  at  right 

FIG.  238. 


angles  downward  and  inward,  and  their  points  sharpened.  Suitable 
spaces  are  made  with  an  excavator  between  bands  and  enamel  on 
the  buccal  sides  of  the  molars,  and  the  points  engaged  in  them. 

An  easier  and  better  method  of  making  attachments  to  the  bicus- 
pids for  their  elevation  is  by  means  of  the  wire  ligatures  made  to 

*Dr.  Calvin  S.  Case  was  first  to  employ  this  principle  in  an  appliance  for 
elevation  of  bicuspids. 


246 


MALOCCLUSION. 


encircle  their  crowns  below  their  gingival  ridges,  as  already  de- 
scribed in  the  case  of  cuspids,  in  treatment  of  cases  belonging  to 
the  first  class.  The  bicuspids  and  molars  are  easily  elevated  by 
this  method,  but  the  degree  to  which  the  incisors  are  shortened  is, 
in  the  experience  of  the  author,  extremely  slight.  This  is  easily 
understood  when  we  remember  the  structure  of  the  peridental 

FIG.  239. 


FIG.  240. 


membrane.  The  author  knows  of  no  practical  device  yet  produced 
for  depressing  these  teeth  in  their  sockets,  owing  to  the  great  force 
necessary  and  the  difficulty  of  securing  anchorage. 

Fig.  240  shows  the  lower  arch  from  the  buccal  aspect  of  the 
case  last  described,  both  before  and  after  the  elevation  of  the  first 
molar  and  bicuspids. 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    I.  247 

Second  Plan  of  Treatment. — The  second  plan  of  treatment  is 
toward  the  ideal,  the  establishing  of  normal  occlusion,  normal  re- 
lations of  the  dental  arches,  and  normal  facial  lines,  as  we  have  al- 
ready noted.  This  means  the  retention  of  all  of  the  teeth,  the' 
restoration  of  each  to  harmony  with  its  line  of  occlusion,  the 
changing  of  the  teeth  from  distal  to  normal  occlusion  by  moving 
the  lower  jaw  forward  and  compelling  normal  closure  of  the  jaw 
by  some  form  of  device  until  the  normal  occlusion  shall  have  been 
thoroughly  established  and  the  jaws  and  muscles,  and  especially 
the  temporo-maxillary  articulation,  shall  have  been  modified  into 
harmony  with  this  changed  occlusion. 

FIG.  241. 


Copyrighted. 

Fig.  241  accurately  illustrates  a  case  which  was  treated  according 
to  this  method.  The  patient  was  a  boy  nine  years  of  age.  It  will 
be  seen  that  the  deciduous  cuspids  and  molars  are  still  in  position, 
while  the  permanent  centrals  and  laterals  are  fully  erupted,  those 
in  the  upper  arch  occupying  positions  of  marked  labial  promi- 
nence. The  extent  of  distal  occlusion  (indicated  by  the  dark  lines 
in  the  engraving)  is  equal  to  the  mesio-distal  diameter  of  a  bicus- 
pid. 

With  the  exception  of  the  somewhat  lengthened  condition  of  the 
lower  incisors,  as  is  usual,  the  arrangement  of  the  teeth  in  the  lower 
arch  is  normal.  The  narrowed  and  lengthened  upper  arch  is  well 
shown  in  Fig.  242,  the  dotted  lines  indicating  the  disto-occlusal 
relation  of  the  lower  teeth. 

The  inharmony  of  the  facial  lines,  as  the  result  of  such  occlusion 


248 


MALOCCLUS1ON. 

FIG.  242. 


FIG.  243. 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    I, 


249 


and  distal  displacement  of  the  lower  jaw,  is  shown  in  Fig.  243, 
although  not  to  so  great  an  extent  as  was  really  existent,  as  the 
portrait  is  not  a  full  profile.  The  facial  lines  after  correction  of 
the  occlusion  are  shown  in  Fig.  244. 

The  length  and  prominence  of  the  incisors  were  reduced  by  the 
arch  :B  and  occipital  anchorage  in  the  usual  way,  as  already  de- 

FIG.  244. 


scribed,  the  dental  arch  being  widened  at  the  same  time  by  the 
spring  of  the  arch  B  and  wire  ligatures.  After  the  positions  of  the 
teeth  and  form  of  the  arch  had  been  modified  to  harmonize  with  the 
normal  line  of  occlusion,  as  shown  in  Fig.  245,  the  widened  arch 
was  retained  by  a  vulcanite  plate. 

As  a  result  of  the  changed  form  of  the  arch,  normal  occlusion  was 
then  possible,  and  the  patient  could  readily  close  the  lower  jaw  for- 
ward into  normal  position.  In  order  to  compel  closure  of  the  jaw 


250 


MALOCCLUSION. 


in  this  position  only,  and  at  the  same  time  provide  a  constant  re- 
minder to  the  patient  of  the  importance  of  keeping  the  jaw  closed 
as  much  of  the  time  as  possible,  the  device  shown  in  Fig.  162  and 
already  described  was  employed.  The  plane  of  metal  anterior 
to  which  the  spur  is  made  to  close  is  shown  in  Fig.  245  soldered  to 
the  buccal  side  of  a  No.  2  band. 

FIG.  245. 


The  corrected  occlusion  and  also  the  retaining  device  are  shown 
in  Fig.  246. 

The  retaining  device  was  alternated  on  opposite  sides  of  the 
mouth  as  the  deciduous  teeth  were  lost  or  the  permanent  teeth 
showed  indications  of  displacement. 

The  patient  was  directed  to  frequently  exert  pressure  of  the 
upper  lip  upon  the  incisors,  for  the  double  purpose  of  stimulating 
its  function  and  to  assist  in  their  retention.  The  further  reten- 
tion of  the  incisors  was  effected  after  the  plans  already  described 
in  the  chapter  on  Retention. 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    I. 


251 


Fig.  247  shows  the  occlusion  of  this  case  more  than  two  years 
after  the  discontinuance  of  all  artificial  retention.  There  can  be 
no  question  as  to  the  permanent  change  in  the  occlusion  of  the 
teeth  and  relations  of  the  jaws ;  or,  in  other  words,  the  so-called 
"jumping  the  bite"  has  been  accomplished. 

FIG.  247. 


FIG.  248. 


This  case  is  of  additional  interest,  as  the  deciduous  upper  in- 
cisors were  also  markedly  protruding,  a  condition  which  must  be 
extremely  rare,  and  which  is  shown  in  the  engraving,  Fig.  248, 
made  from  a  photograph  taken  at  the  age  of  two  years,  and  yet  the 
cause  could  not  be  traced  to  the  habit  of  exerting  pressure  by  the 
lip,  tongue,  or  finger,  or  to  heredity. 


2^2 


MALOCCLUSION. 


Fig.  249  shows  another  case  belonging  to  Division.  I  of  Class  II, 
and  treated  also  after  the  second  plan.  There  was  complete  distal 
occlusion,  as  indicated  by  the  dark  lines  in  the  engraving,  and  very 
pronounced  prominence  of  the  upper  incisors. 

FIG.  249. 


The  patient  was  a  miss  fourteen  years  of  age,  and  although  her 
age  seemed  to  be  unfavorable  to  this  plan  of  treatment,  yet  her 
intelligence  and  determination  were  such  as  to  lend  much  encour- 
agement 

Fig.  250  shows  the  upper  arch  from  the  occlusal  aspect,  the' 


TREATMENT    OF    CASES. CLASS    II,    DIVISION     I.  253 

dotted  lines  showing  the  relation  of  the  lower  arch.  The  arch  B, 
held  in  position  by  the  anchor  bands  D  upon  the  first  molars,  are 
also  well  shown,  with  attachments  to  the  plain  bands,  as  in  A,  Fig. 

233- 

In  order  to  widen  the  arch  in  the  region  of  the  cuspids  and  bi- 
cuspids so  that  the  lower  arch  might  be  moved  forward  from  distal 
to  normal  occlusion,  the  first  bicuspids  were  laced  to  the  wire  arch, 
it  having  been  first  bent  to  give  the  full  spring,  while  the  cuspids 
were  moved  by  that  simple  and  most  effective  plan  of  lengthening 
a  section  of  the  wire  G  with  the  regulating  pliers,  Fig.  70.  The 
ends  of  the  wire  were  made  to  rest  in  tubes  R  soldered  at  right 
angles  to  the  lingual  surfaces  of  plain  bands  cemented  on  the 
crowns  of  the  cuspids.  Of  course  the  jack-screw  might  have  been 
used  instead  of  this  device,  or  ligatures  svtrrounding  the  arch  and 
teeth  in  the  usual  way,  but  as  it  was  desired  to  accomplish  the 
various  tooth  movements  rapidly  the  former  plan  was  employed, 
and  the  author  prefers  it. 

Only  one  of  the  delicate  retaining  rubber  ligatures  is  shown  in 
the  engraving — on  the  left. 

Sections  of  bone  were  removed,  as  elsewhere  described,  and  as 
shown  by  the  crescent-shaped  markings  in  the  engraving,  in  order 
to  expedite  the  movement  of  the  incisors.  Force  was  exerted  upon 
the  incisors  by  means  of  the  head-gear  in  the  usual  way,  worn 
almost  constantly  for  six  weeks.  The  arch  had  then  been  changed 
in  form  to  that  shown  in  Fig.  251. 

Of  course  it  was  necessary  to  modify  the  form  of  the  arch  B 
occasionally  during  this  period,  and  also  to  perform  rotation  of  the 
lateral  incisors  by  means  of  spurred  bands,  ligatures,  and  rubber 
wedges,  in  the  usual  way. 

Originally  the  lower  incisors  occupied  the  position  of  malcc- 
clusion  which  is  quite  uniform  in  all  such  cases, — namely,  ele- 
vated in  their  sockets,  slightly  irregular  as  to  alignment,  and  with 
lingual  inclination.  They  were  corrected  in  the  usual  way. 

The  teeth  of  both  arches  having  been  placed  in  harmony  with 
their  lines  of  occlusion,  the  lower  jaw  could  then  be  easily  moved 
forward  and  the  teeth  could  occlude  normally,  as  shown  in  Fig.  252. 

For  compelling  the  normal  closure  of  the  jaw  the  device  pre- 
viously described  and  shown  in  Fig.  163  was  employed. 

A  section  of  the  wire  G  is  shown  crossing  the  labial  surfaces  of 


254 


MALOCCLUS1ON. 


the  lower  incisors  for  effecting  their  retention,  after  the  plan  shown 
in  Fig.  149,  and  described  in  the  chapter  on  Retention. 

The- changes  in  the  facial  lines  resulting  from  the  changed  oc- 
clusion are  shown  in  Figs.  253  and  254. 

FIG.  251. 


FIG.  252. 


Dr.  H.  A.  Baker,  of  Boston,  in  a  case  belonging  to  this  class — 
that  of  his  son — illustrated  in  Fig.  255,  employed  a  novel  and 
valuable  method  of  exerting  force  for  the  reduction  of  protruding 
upper  incisors,  using  for  anchorage  the  teeth  of  the  lower  jaw  and 
exerting  force  by  means  of  heavy  elastic  ligatures,  one  end  being 
secured  to  the  author's  arch  B  in  front  of  the  small  immovable 


TREATMENT   OF    CASES. CLASS    II,    DIVISION    I. 


255 


collars  in  the  usual  way,  the  other  end  being  drawn  back  and 
hooked  over  the  distal  ends  of  the  tubes  of  the  D  bands  on  the  lower 
second  molars,  these  tubes  also  being  used  to  support  the  ends  of 
the  expansion  arch,  which  served  the  double  purpose  of  correcting 

FIG.  253. 


some  slight  malarrangement  of  the  teeth  of  the  lower  arch,  as  well 
as  reinforcing  the  teeth  used  as  anchorage. 

Excellent  results  are  shown  in  the  completed  case,  Fig.  256,  and 
the  very  gratifying  improvement  in  the  facial  lines  is  shown  by 
comparing  Figs.  257  and  258. 


256 


MALOCCLUS1ON. 

FIG.  254. 


FIG.  2$$. 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    I.  257 

FIG.  256. 


FIG.  257. 


18 


258  MALOCCLUSIOX. 

If  we  will  study  this  method  of  applying  force  we  will  see  that 
it  possesses  several  valuable  features.  First,  it  tends  to  harmonize 
the  sizes  of  the  arches  by  shortening  the  upper  arch,  as  well  as 
moving  all  the  upper  teeth  distally,  and  at  the  same  time  lengthen- 
ing the  lower  arch  by  moving  all  the  lower  teeth  mesially,  or  the 
employment  to  its  greatest  degree  of  that  excellent  form  of  anchor- 

FIG.  258. 


age — reciprocal.  Another  advantage  is  a  tendency  to  lengthen  the 
bite  by  slight  elevation  of  the  lower  molars,  usually  desirable  in 
these  cases. 

The  only  objection  to  its  use  which  the  author  has  so  far  found 
is,  that  as  the  force  upon  the  protruding  incisors  is  exerted  down- 
ward as  well  as  backward  they  are  lengthened,  instead  of  being 
depressed  in  their  sockets,  as  they  should  be  in  so  large  a  percent- 


TREATMENT    OF    CASES.— CLASS    II,    DIVISION    I.  259 

age  of  cases  belonging  to  this  class.  But  this  objection  is  easily 
overcome  and  the  time  of  treatment  greatly  shortened  by  com- 
bining this  form  of  anchorage  with  occipital  by  means  of  the  head- 
gear and  traction  bar  in  the  usual  way.  This  combination  is  the 
author's  favorite  plan.  Another  reason  for  combining  occipital  an- 
chorage with  reciprocal  in  these  cases  is,  that  it  is  well  known  that 
more  force  is  required  to  move  the  teeth  distally  than  mesially  (the 
natural  tendency  of  the  teeth  of  both  arches  being  to  move  for- 
ward), so  the  additional  force  of  the  occipital  anchorage  is  needed, 
otherwise  there  will  be  unequal  movement  of  the  teeth  in  the  two 
arches,  the  lower  moving  the  faster.  By  such  combination  we  have 
the  greatest  control  over  the  movements  of  the  teeth  in  both  arches, 
and  these  cases  which  have  always  been  regarded  as  so  tedious  and 
protracted  are  now  easily  brought  to  the  period  of  retention  in 
treatment  in  a  very  few  weeks. 

In  making  use  of  this  additional  form  of  anchorage  the  author's 
plan  is  to  adjust  the  appliances  upon  the  upper  dental  arch  in  the 
same  manner  as  already  described,  according  as  the  plan  of  treat- 
ment shown  in  Figs.  235  or  250  is  to  be  employed,  but  before  slip- 
ping the  arch  B  into  final  position  two  projecting  spurs  for  engag- 
ing heavy  ligatures  are  attached  to  its  under  surface  just  anterior  to 
the  small,  immovable  collars  always  found  upon  the  sides  of  these 
arches.  These  spurs  are  best  made  from  sections  of  wire  G,  bent 
as  in  Fig.  259,  and  flattened  on  one  side  for  about  one-fourth  of 
an  inch  in  order  to  lie  in  closer  contact  with  the  arch  B,  as  well 
as  to  afford  greater  surface  for  the  solder  in  its  attachment.  The 
arch  B  at  its  point  of  attachment  should  also  be  slightly  flattened 
by  filing.  The  solder  used  in  attaching  these  spurs  should  of 
course  be  soft  and  a  most  delicate  flame  slowly  applied,  the  same  as 
in  making  similar  attachments  already  described  in  the  chapter  on 
Soldering.  After  soldering,  the  surplus  wire  is  cut  off  and  the  end 
smoothed,  all  as  shown  in  Fig.  259. 

The  form  of  elastic  which  has  proven  the  most  satisfactory  is 
the  red  rubber  band  for  jewelers'  use,  No.  20.  In  adjusting  it  it 
is  doubled,  the  two  sides  of  the  rubber  at  the  middle,  B,  being 
caught  over  the  distal  end  of  the  sheath  of  the  D  band  on  the  lower 
dental  arch,  the  two  ends,  C  C,  carried  forward  and  slipped  over 
the  spur  on  the  arch  B  on  the  upper  dental  arch,  as  in  Fig.  260.  As 
the  ligatures  engage  only  the  sheaths  of  the  D  bands  on  the  lower 


260 


MALOCCLUSION. 


arch  it  might  at  first  seem  that  these  bands,  or  the  No  2  bands  with 
suitable  spurs  attached  for  the  reception  of  the  ligatures,  or  the 
fracture  bands,  would  be  sufficient  without  the  addition  of  the 
expansion  arch,  but  it  is  very  important  that  it  should  be  used  in 
connection  with  the  D  bands  for  steadying  and  controlling  the  posi- 


FIG.  259. 


FIG.  260. 


tions  of  these  anchor  teeth,  otherwise  they  would  become  rotated  or 
displaced  laterally.  It  is  important  to  remember,  however,  that  in 
thus  using  the  expansion  arch  it  must  be  left  free  from  attachments 
by  ligatures  in  front,  that  it  may  tip  downward  as  the  teeth  are  made 
to  incline  forward  through  the  force  exerted  upon  them  by  the 
strong  elastic  ligatures.  If  at  any  time,  however,  we  wish  to  arrest 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    I.  26l 

the  further  tipping  movement  of  the  teeth,  we  have  but  to  firmly 
lace  the  incisors  to  the  expansion  arch,  when  we  will  have  changed 
our  anchorage  from  simple-reciprocal  to  stationary-reciprocal.  On 
the  other  hand,  by  bending  the  expansion  arch  upward  at  its  en- 
gagement with  the  sheaths  of  the  D  bands,  then  springing  the  an- 
terior part  downward  and  lacing  to  the  incisors,  we  shall  exert 
a  prying  influence  upon  the  anchor  teeth  which  will  tend  to  tip 
them  forward  and  assist  the  ligatures.  So  by  taking  advantage  of 
these  possibilities  we  may  control  absolutely  the  movements  of 
the  teeth  of  the  lower  arch,  completely  arresting  or  hastening  the 
movements  of  either  one  or  both  of  its  lateral  halves.  The  same 
principles  are  applicable  through  the  arch  B  in  controlling  the 
movements  of  the  upper  teeth,  and  by  studying  and  employing 
them  we  may  bring  about  results  in  occlusion  and  facial  lines  other- 
wise impossible.  The  extent  of  usefulness  of  the  Baker  form  of 
anchorage  cannot  be  well  estimated. 

After  complete  harmony  as  to  sizes  of  the  arches  and  relations 
of  the  teeth  has  been  gained,  the  relations  of  the  first  molars  should 
be  carefully  maintained  by  double  bands,  spur  and  metal  plane,  as 
in  Fig.  162,  which  may  be  changed  to  or  alternated  with  the  plan 
shown  in  Fig.  163. 

Dr.  Baker's  method  of  retention  is  shown  in  Chapter  XII. 

Class  II. — Subdivision  of  Division  1. 

As  practically  the  same  conditions  are  met  in  cases  belonging 
to  this  subdivision  as  are  found  in  the  main  division,  just  de- 
scribed, the  only  difference  being  the  normal  relations  of  the  lateral 
halves  of  the  arches  on  one  side,  Fig.  261,  the  plan  of  treatment 
and  the  appliances  used  must  naturally  be  similar.  As  there  is 
inharmony  as  to  size  of  the  two  arches  to  the  extent  of  one  bicuspid 
it  must  follow  that  the  plan  of  treatment  clearly  indicated,  especially 
in  fully  developed  cases,  requires  the  extraction  of  the  first  upper 
bicuspid  on  the  abnormal  side  and  the  movement  distally  of  the 
incisors  and  cuspid  until  the  space  shall  be  completely  closed.  We 
must  then  have  harmony  in  the  sizes  of  the  arches  and  in  the  rela- 
tions of  the  occlusal  planes. 

This  was  accomplished  in  the  case  shown  with  the  combination  of 
the  arch  B  and  traction  screw  on  the  affected  side,  as  described 
elsewhere  and  shown  in  Fig.  262,  which  accurately  illustrates  the 


262 


MALOCCLUSION. 


case  nearing  completion.     The  other  lateral  half  of  the  dental  arch 
being  normal,  the  end  of  the  arch  B  was  supported  in  the  usual  way 


FIG.  261. 


FIG.  262. 


Copyrighted. 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    2.  263 

by  the  band  D,  with  omission  of  the  delicate  rubber  ligature.  The 
ligature  on  the  abnormal  side  is  also  omitted  from  the  engraving. 
It  is  important,  however,  that  it  be  used. 

It  being  necessary  to  shift  the  incisors  to  the  right  as  they  were 
moved  lingually  in  order  to  place  them  in  better  harmony  with 
the  median  line,  this  was  effected  by  deflecting  the  force  from  the 
head-gear  laterally  by  the  wearing  of  a  small  cushion  between  the 
cheek  and  heavy  elastics  on  the  abnormal  side,  thus  exerting  a  ro- 
tatory force  on  the  arch  B. 

The  central  incisor  was  carried  laterally  by  being  laced  to  the 
arch,  the  wire  ligature  bearing  against  the  minute  ball  in  the  center 
of  the  arch,  as  shown  in  the  engraving. 

The  incisors  were  retained  after  the  usual  plans  already  de- 
scribed; the  cuspid,  after  the  plan  shown  in  Fig.  153. 

It  sometimes  happens  in  these  cases  that  the  lower  teeth  on  the 
abnormal  side  are  not  all  in  full  distal  occlusion,  being  appar- 
ently in  the  transitional  stage.  This  does  not  change  the  plan  of 
treatment,  except  that  a  slight  forward  movement  of  the  anchor 
teeth  may  then  usually  be  permitted,  that  the  distal  relations  of  the 
lower  occlusal  planes  may  be  complete.  In  such  cases,  if  the  pa- 
tients be  young,  the  Baker  method  of  anchorage  may  be  employed 
for  shifting  distally  the  teeth  of  the  upper  arch  and  mesially  those  of 
the  lower,  thus  avoiding  extraction. 


CHAPTER    XIX. 

TREATMENT   OF    CASES. CLASS    II,    DIVISION    2. 

IT  will  be  remembered  that  in  cases  of  malocclusion  belonging  to 
this  division  of  Class  II,  as  in  those  of  Division  I,  the  teeth  of  the 
lower  arch  are  in  distal  occlusion  in  both  its  lateral  halves.  The 
upper  arch,  unlike  that  of  cases  of  Division  I,  which  is  abnormally 
long  and  narrow,  is  shortened,  with  incisors  bunched  and  overlap- 
ping, as  in  Fig.  263,  to  approximately  harmonize  in  size  with  the 
anterior  part  of  the  lower  arch.  Unlike  the  conditions  of  the  other 
division,  the  incisors  are  not  elevated  in  their  sockets,  owing  prob- 
ably to  their  more  nearly  normal  function,  and  there  are  normal 


264  MALOCCLUSION. 

respiration  and  lip  function,  but  the  result  of  distal  occlusion  and 
sub-mental  development  greatly  modifies  the  facial  line  of  harmony, 
as  in  the  cases  of  the  other  division,  see  Fig.  27,  the  effect  being 
very  similar  to  cases  belonging  to  Division  i,  after  treatment  by  the 
first  plan,  Fig.  237. 

As  in  the  other  division,  there  are  two  plans  of  treatment  which 
may  be  followed  in  these  cases.  As  before  said,  the  first  has  for  its 
object  the  improvement  of  occlusion  only,  while  the  second  has  for 
its  object  not  only  the  establishment  of  normal  occlusion,  but  the 
best  attainable  degree  of  improvement  of  the  contour  of  the  face, 
being  an  effort  toward  the  ideal. 

FIG.  263. 


In  following  the  first  plan  the  extraction  of  two  bicuspids,  pref- 
erably the  first,  is  clearly  indicated,  with  the  retraction  of  the 
cuspids  to  close  the  spaces,  followed  by  the  correct  adjustment  of 
the  incisors. 

For  accomplishing  these  tooth  movements  the  combination  of 
traction  screws,  anchor  bands,  expansion  arch,  spurred  bands,  and 
ligatures,  as  already  described  and  as  shown  on  one  side  in  Fig.  129, 
should  be  employed.  It  will  thus  be  seen  that  if  the  cuspids  have 
been  properly  retracted  and  the  incisors  correctly  adjusted  there 
will  then  be  marked  improvement  in  the  occlusion  and  complete  har- 
mony in  the  sizes  of  the  arches. 

In  pursuing  the  second  plan  of  treatment  the  expansion  arch, 
bands  D,  spurred  bands,  and  ligatures  only  are  used,  to  move 
labially  and  into  harmony  with  the  line  of  occlusion  the  incisors, 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    2. 


265 


after  the  plan  already  described  in  the  treatment  of  cases  belonging 
to  the  first  class,  and  as  shown  in  Fig.  126.  The  lower  jaw  is  then 
made  to  close  forward  and  the  occlusion  of  the  teeth  changed  from 

FIG.  264. 


FIG.  265. 


distal  to  normal  in  the  same  manner  and  with  the  same  devices  as 
already  described  and  illustrated,  Figs.  162  and  163. 

Fig.  264  represents  the  upper  arch  of  the  case  shown  in  F%  126, 
while  Fig.  265  shows  the  same  arch  after  it  had  been  enlarged,  with 
the  expansion  arch,  ligatures,  etc.,  still  in  position. 


266  MALOCCLUS1ON. 

Fig.  12  shows  the  profile  of  the  patient  at  the  beginning  of  treat- 
ment, while  Fig.  13  shows  the  changes  in  the  facial  lines  as  the 
result  of  the  restoration  from  distal  to  normal  occlusion. 

As  the  patient  was  twenty-one  years  of  age,  there  was  some 
doubt  as  to  whether  the  jaw  and  temporo-maxillary  articulation 
would  be  modified  to  harmonize  with  the  new  conditions  and  in- 
sure permanency  of  the  changes.  A  protracted  period  of  retention, 
however,  established  the  desired  result. 

It  must  be  remembered  that  in  the  treatment  of  cases  belonging 
to  this  division  after  this  plan  we  have  much  to  favor  us  in  our 
efforts,  in  that  the  patients  are  normal  breathers  and  the  mouth  is 
kept  closed,  and  the  teeth  kept  in  occlusion  the  requisite  amount  of 
time.  Certainly  the  results  are  so  gratifying  that  they  are  worthy 
of  our  best  efforts.  Should  we  fail  no  ill  results  will  follow,  and 
we  still  have  the  first  plan  of  treatment  to  resort  to.  Of  course 
what  has  been  said  in  regard  to  the  importance  of  the  restoration  of 
all  teeth  in  both  arches  to  harmony  with  their  lines  of  occlusion 
is  of  equal  importance  in  these  cases,  and  must  not  be  ignored. 

Class  II. — Subdivision  of  Division  2. 

In  cases  belonging  to  this  subdivision  the  conditions  and  indica- 
tions for  treatment  on  the  abnormal  side  are  similar  to  those  in 
Division  I,  Class  II,  just  described,  while  on  the  side  in  which  the 
mesio-distal  relation  of  the  arches  is  normal  any  malposed  teeth 
would  require  the  same  treatment  as  in  cases  belonging  to  Class  I. 
So  the  treatment  for  the  typical  case,  shown  in  Fig.  266,  clearly 
indicated  the  sacrifice  of  the  first  upper  bicuspid  on  the  abnormal 
side  in  order  that  the  arch  might  be  reduced  in  size  to  conform  to 
that  of  the  lower.  The  distal  movement  of  the  cuspid  is  effected 
by  the  traction  screw,  while  the  correction  of  the  malpositions  of  the 
incisors  is  accomplished  by  the  wire  ligatures  and  spurred  bands 
operating  in  connection  with  the  arch  E  in  the  usual  way,  all-  as 
well  shown  in  Figs.  267  and  268. 

On  the  right  side  is  shown  a  block  of  rubber  between  the  arch  and 
cuspid,  which  is  for  the  purpose  of  reducing  the  prominence  of  this 
tooth  as  space  is  provided  for  its  reception  by  the  gradual  shifting 
to  the  left  of  the  incisors  by  the  tightening  of  the  nut  in  front  of  the 
anchor  tube  D.  The  direction  of  force  given  the  incisors  through 
the  spurred  bands  and  ligatures  is  controlled  by  the  spurs  on  the 


TREATMENT    OF    CASES. CLASS    II,    DIVISION    2. 


267 


expansion  arch,  as  before  described  and  as  shown  in  the  engravings. 
In  this  case  the  elevation  of  the  cuspid  was  later  accomplished  by 
tightly  twisting  a  ligature  about  its  neck  above  the  gingival  ridge, 


FIG.  266. 


FIG.  267. 


Copyrighted. 


268 


MALOCCLUSION. 


then  inclosing  the  arch  with  the  ends  and  giving  them  a  second 
twist,  as  before  described. 

FIG.  268. 


E.  HA 
Copyrighted. 


The  cuspids  and  incisors  were  retained  after  the  plans  already 
described  in  the  chapter  on  Retention. 


CHAPTER   XX. 

TREATMENT    OF    CASES. — CLASS    III,    DIVISION. 

IT  will  be  remembered  that  the  distinguishing  characteristic  of 
cases  belonging  to  this  class  and  division  is  mesial  occlusion  of  both 
lateral  halves  of  the  lower  arch,  with  greater  or  less  unevenness  in 
the  arrangement  of  the  teeth,  though  usually  this  is  not  extensive. 
As  the  malocclusion  is,  in  most  cases,  due  to  the  asymmetrical 
development  of  the  jaw-bones,  our  opportunities  for  improving  the 
occlusion  by  working  upon  the  teeth  alone  are,  in  many  cases, 
greatly  limited,  and  are  usually  diminished  in  proportion  to  the  age 
of  the  patient. 

These  cases  are  nearly  always  progressive,  and  if  treatment  is 
begun  very  early  much  may  be  accomplished ;  but  if  delayed  until 
maturity,  when  the  bone  has  become  dense  and  fully  formed,  we 
are  powerless  to  materially  improve  the  conditions  by  ordinary 
methods,  and  are  limited  to  the  operation  of  double  resection  of 
the  lower,  maxilla,  as  shown  in  Chapter  XIV. 


TREATMENT    OF    CASES. — CLASS    III,    DIVISION. 


269 


Not  only  is  the  greatest  possible  degree  of  malocclusion  reached 
in  this  class  of  cases,  but  also  the  greatest  disturbance  to  the  facial 
lines,  an  unpleasing  appearance  being  always  produced,  even  in  the 
simplest  cases  as  in  Fig.  269,  while  in  some  extreme  cases,  as  shown 
in  Figs.  9  and  279,  the  inharmony  amounts  to  a  most  pronounced 
deformity,  constantly  attracting  attention  and  comment,  and  if  the 

FIG.  269. 


patient  be  of  a  sensitive  nature  the  condition  becomes  truly  pathetic. 
The  inability  of  the  patient  to  close  the  lips  and  control  sounds 
renders  the  correct  enunciation  of  many  words  impossible. 

In  order  to  improve  the  facial  lines  and  occlusion  and  establish 
harmony  in  the  sizes  of  the  arches  there  are  four  different  plans  of 
treatment  which  may  be  followed,  limited  in  their  application  to  the 
conditions  found  to  exist  in  each  given  case :  First,  retraction  of 
the  inferior  maxilla ;  second,  enlarging  the  superior  dental  arch  to 
its  normal  size ;  third,  enlarging  the  upper  arch  beyond  its  normal 


270 


MALOCCLUSION. 


size ;  fourth,  diminishing  the  size  of  the  lower  arch.     Of  course, 
we  may  often  combine  two  or  more  of  these  plans. 

In  employing  the  first  plan  the  position  of  the  lower  jaw  is  modi- 
fied by  the  use  of  the  chin  retractor  and  occipital  anchorage,  as 
shown  in  Fig.  270.  Where  much  may  be  accomplished  by  this 
method  if  employed  while  the  patient  is  young  and  the  bone  yield- 
ing, little  can  be  hoped  for  in  its  use  after  the  age  of  fifteen,  yet  in 
some  cases  even  later  the  author  has  been  able  to  produce  very 
gratifying  changes  with  it. 

FIG.  270. 


The  principal  reason  why  more  is  not  accomplished  by  this  method 
of  treatment  is  that  the  time  of  wearing  the  chin  retractor  is  usually 
very  limited.  Could  the  patient  be  placed  in  surroundings  where 
social  duties  would  not  interfere,  so  that  pressure  might  be  exerted 
in  this  way  systematically  for  several  months,  it  is  quite  probable 
that  marked  changes  might  be  produced,  even  in  case  of  patients  at 
as  advanced  an  age  as  twenty  years;  but  with  the  wearing  of  the 
appliance  for  a  few  hours  at  night  only,  with  complete  removal  dur- 
ing the  remaining  time,  little,  if  any,  improvement  is  to  be  hoped 
for. 

In  the  use  of  the  chin  retractor  very  light  pressure  should  at  first 
be  employed,  gradually  increasing  it  as  the  patient  becomes  ac- 
customed to  wearing  it,  always  observing  the  greatest  care  to  pre- 


TREATMENT    OF    CASES. CLASS    III,    DIVISION. 


271 


vent  irritation  of  the  chin  by  placing  fresh  antiseptic  cotton  between 
the  metal  cap  and  the  chin  at  regular  intervals  of  a  few  hours. 

Fig.  271  represents  the  side  view  of  a  case  of  a  child  nine  years 
of  age.  The  permanent  incisors  of  the  lower  jaw  had  erupted;  the 
superior  centrals  had  also  erupted  and  were  twisted  nearly  at  right 
angles.  The  deciduous  cuspids  were  in  position,  although  the  in- 
ferior were  loosened  and  nearly  ready  to  fall  out.  The  four  per- 
manent first  molars  were  present,  and  the  first  superior  bicuspids 
were  beginning  to  emerge  from  the  gum.  The  jaw  had  moved 

FIG.  271. 


FIG.  272. 


forward  so  that  the  lower  incisors  closed  anterior  to  the  upper,  all 
as  correctly  represented  in  the  engraving.  The  patient  could  not 
retract  the  jaws  sufficiently  to  bring  the  cutting-edges  of  the  in- 
cisors in  contact  at  any  point. 

Double  rotation  of  the  superior  centrals  was  accomplished  by 
means  of  the  lever  already  described  in  double  rotation,  Fig.  no. 
They  were  retained  by  uniting  the  bands  with  solder  and  re-cement- 
ing them  upon  the  teeth.  The  chin  retractor  and  head-gear  were 
worn  almost  constantly  for  six  weeks,  and  at  the  end  of  this  time 
the  jaw  had  been  retracted  into  almost  normal  position,  presenting 
the  appearance  shown  in  Fig.  272.  At  the  end  of  this  time  the 


272  MALOCCLUSION. 

chin  retractor  and  head-gear  were  worn  at  night  only,  with  light 
tension,  and  entirely  dispensed  with  after  six  months,  as  there  was 
no  need  of  further  retractive  force. 

The  second  plan  of  treatment  is  that  of  enlarging  the  upper  dental 
arch  to  its  normal  size  by  placing  each  malposed  tooth  in  correct 
position,  which  may  be  accomplished  by  means  of  the  usual  com- 
bination of  expansion  arch,  wire  ligatures,  and  spurred  bands. 

The  case  shown  in  Fig.  273  was  that  of  a  young  lady  thirteen 
years  of  age.  It  is  readily  apparent  from  a  glance  at  the  mesio- 
buccal  cusp  of  the  upper  first  molar  that  it  belonged  to  the  third 
class  of  malocclusion.  The  condition  was  further  intensified  by  the 

FIG.  273. 


contraction  of  the  anterior  part  of  the  upper  arch  until  the  distal 
incline  of  the  lateral  incisor  occluded  with  the  first  bicuspid,  and 
although  the  inferior  incisors  inclined  lingually,  their  cutting-edges 
were  considerably  labial  to  the  superior  incisors.  Fortunately,  the 
case  was  not  further  complicated  by  the  loss  of  any  of  the  teeth. 

Of  the  four  possible  methods  of  treatment  two  admit  of  appli- 
cation in  this  case.  First,  the  enlarging  of  the  upper  arch  and  the 
shifting  of  the  incisors  laterally  sufficiently  to  admit  of  the  impacted 
cuspid  being  drawn  into  occlusion,  and  second,  the  retraction  of  the 
lower  jaw. 

The  former  was  accomplished  by  means  of  the  appliance  so  well 
shown  in  position  upon  the  teeth.  As  it  was  necessary  to  shift  the 
incisors  to  the  left  in  order  to  restore  them  to  harmony  with  the 
median  line,  this  was  accomplished  simultaneously  with  their  move- 


TREATMENT    OF    CASES. CLASS    III,    DIVISION.  273 

ment  forward  by  force  exerted  on  one  side  only,  by  tightening  the 
nut  in  front  of  the  anchor  tube  on  the  right.  It  will  be  noticed  in 
the  engraving  that  several  short  spurs  have  been  soldered  to  the 
expansion  arch,  just  anterior  to  the  ligatures  encircling  the  incisors, 
which  serve  the  very  important  purpose  of  preventing  the  expansion 
arch  from  sliding  through  the  ligatures  and  toward  the  left  without 
materially  moving  the  incisors,  as  would  have  been  the  result  had 
not  the  spurs  been  so  placed. 

The  cuspid  was  drawn  into  the  line  of  occlusion  by  means  of  a 
ligature  made  to  encircle  the  arch  and  a  common  pin  accurately 
fitted  and  cemented  into  a  cavity  made  in  the  enamel  on  the  labial 

FIG.  274. 


surface  of  the  tooth,  to  accomplish  which  it  was  necessary  to  lance 
the  gum  and  impact  a  pledget  of  cotton,  which  was  worn  for  two 
or  three  days,  in  order  to  expose  sufficient  tooth-surface. 

The  somewhat  prominent  first  bicuspid  was  reduced  by  an  inter- 
vening wedge  of  rubber,  also  well  shown  in  the  engraving. 

While  the  teeth  in  the  upper  arch  were  being  drawn  into  the  line 
of  occlusion,  the  head-gear  and  chin  retractor  were  being  worn 
almost  constantly. 

Fig.  274  shows  the  completed  case  and  the  only  retention  neces- 
sary, the  teeth  being  supported  in  their  new  positions  principally  by 
occlusion,  the  cuspid  being  retained  by  a  spur  soldered  to  the  band 
on  the  lateral  incisor  and  made  to  bear  upon  the  pin  already  in 
position. 

'9 


2/4 


MALOCCLUSION. 


The  wearing  of  the  chin  retractor  was  continued  with  diminishing 
force  for  two  or  three  months  longer. 

It  should  be  added  that  a  slight  downward  spring  was  given  to 
the  expansion  arch  while  the  teeth  were  being  moved  outward,  in 
order  to  slightly  lengthen  the  incisors,  and  some  depression  of  the 
molars  was  thus  gained.  The  retraction  of  the  maxilla  was  effected 
by  the  adjustment  of  the  ligatures  from  the  chin  retractor  to  the 
head-gear  in  such  manner  as  to  exert  pressure  upward  as  well  as 
backward,  the  result  of  all  being  to  make  a  greater  overbite  and 
more  effectual  retention  of  the  incisors. 

FIG.  275. 


FIG.  276. 


Fig.  275  shows  another  case  from  the  buccal  aspect  of  one  side, 
and  Fig.  276  accurately  represents  the  upper  arch  from  the  occlusal 
aspect.  The  case  was  treated  by  a  combination  of  the  first  and 
second  plans,  or  enlargement  of  the  upper  arch  in  the  usual  manner 
and  retraction  of  the  lower  jaw  with  the  chin  retractor  and  occipital 
anchorage,  as  already  described. 


TREATMENT    OF    CASES. CLASS    III,    DIVISION. 


275 


At  the  end  of  two  months  the  expansion  qf  the  upper  arch  was 
discontinued,  the  teeth  retained,  and  the  patient  allowed  to  return 
to  her  home  in  a  distant  city  for  a  vacation  of  three  months.  This 
was  done  in  order  to  give  the  upper  jaw  an  opportunity  to  develop, 
but  the  wearing  of  the  chin  retractor  was  continued  faithfully.  At 
the  end  of  the  three  months  the  patient  returned  and  the  expansion 

FIG.  277. 


E.H.A 


FIG.  278. 


of  the  upper  arch  was  continued,  at  the  same  time  the  tension  upon 
the  chin  being  increased.  Two  months  later  the  enlargement  of 
the  upper  arch  had  been  completed,  and  is  truthfully  represented  in 
Fig.  277.  The  lower  jaw  had  been  moved  backward,  and  the 
occluding  teeth  presented  the  appearance  shown  in  Fig.  278.  The 
improvement  in  the  facial  lines  is  shown  by  comparing  Figs.  279 

and  280. 

In  the  third  plan  of  treatment  the  upper  arch  may  be  enlarged 
beyond  the  normal  by  lengthening  one,  or  possibly  both,  of  its 


276  MALOCCLUSION. 

lateral  halves  in  the  region  of  the  bicuspids,  and  the  space  closed  by 
some  form  of  artificial  tooth  which  shall  act  at  the  same  time  as  a 
retainer.  This  form  of  treatment  cannot  of  course  be  employed 
unless  the  development  of  the  upper  jaw  is  such  that  the  incisors 
and  cuspids  will  not  occupy  positions  of  too  great  an  angle  after 
being  moved  forward.  The  author  has  followed  this  plan  of  treat- 
ment in  two  cases  writh  marked  success. 

The  fourth  plan  of  treatment  consists  in  reducing  the  size  of  the 
lower  arch  after  extraction  of  the  first  bicuspids.     This  plan  of 

FIG.  279. 


treatment  will  rarely  be  found  practicable,  as  one  of  the  character- 
istics almost  always  present  in  cases  belonging  to  this  class  is  the 
marked  lingual  inclination  of  the  lower  incisors  and  cuspids,  due 
to  the  pressure  of  the  lower  lip  in  the  effort  to  close  the  mouth. 

Fig.  281  illustrates  a  case  in  which  the  first,  second,  and  fourth 
plans  of  treatment  were  combined.  The  upper  anterior  teeth  were 
moved  outward  by  means  of  the  jack-screws,  as  shown  in  position 
upon  the  teeth  in  Fig.  282.  After  the  first  bicuspids  had  been 
extracted,  contraction  of  the  anterior  part  of  the  inferior  arch  was 
accomplished  by  means  of  the  traction  screws  hooked  into  staples 


TREATMENT    OF    CASES. CLASS    III,    DIVISION. 


2/7 


on  bands  encircling  the  cuspids.     The  traction  screws  were  assisted 
in  moving  the  cuspids  and  incisors  backward  by  the  head-gear, 


FIG.  280. 


FIG.  281. 


elastics,  and  traction  bar,  they  exerting  pressure  upon  a  section  of 
the  arch  B,  which  rested  in  contact  with  the  incisors  and  cuspids, 


278 


MALOCCLUSION. 


being  held  in  position  by  the  attachment  of  the  band  to  the  ends 
with  solder,  all  as  shown  in  Fig.  283.  The  combination  shown  in 
Fig.  235  would  perfectly  meet  the  requirements  if  intelligently 
adjusted  and  operated  on  the  lower  arch.  The  external  force  served 
the  double  purpose  of  assisting  the  traction  screws  in  moving  the 
teeth  and  of  the  retraction  of  the  maxilla.  The  degree  of  success 

FIG.  282. 


FIG.  283. 


achieved  in  the  last-mentioned  movement  was  quite  noticeable,  as 
is  well  shown  in  Fig.  284,  which  represents  the  completed  case. 

It  must  be  borne  in  mind  that  the  force  necessary  to  carry  back 
both  cuspids  and  incisors  is  considerable,  and,  as  we  are  somewhat 
at  a  disadvantage  in  exerting  force  upon  teeth  in  the  lower  arch  by 
means  of  occipital  anchorage,  more  time  and  care  are  necessary 
than  in  producing  the  same  tooth  movements  in  the  upper  arch. 
The  head-gear  should  be  worn  low  upon  the  neck.  Sometimes  it  is 


TREATMENT   OF   CASES. — CLASS  III,   SUBDIVISION.  279 

of  advantage  to  use,  instead  of  the  head-gear,  a  broad  band  con- 
structed from  cloth  for  the  occasion,  which  shall  bear  upon  the 
neck  only,  and  to  which  the  elastics  are  to  be  attached,  but  in  every 
instance  it  must  be  adjusted  so  as  not  to  exert  pressure  at  such 
an  angle  upon  the  teeth  as  will  elevate  them  in  their  sockets  as  they 
move  distally. 

These  cases  are  often  troublesome,  calling  for  our  best  skill, 
judgment,  and  patience,  and  yet  the  results  often  wholly  within 
the  possibilities  are  worthy  of  our  very  best  efforts. 

FIG.  284. 


Class  III. — Subdivision. 

The  mesio-distal  relations  of  the  arches  in  cases  belonging  to 
this  division  are  normal  on  one  side  and  mesial  on  the  other,  as 
shown  in  Fig.  31.  As  the  lower  arch  is  larger  than  the  upper  to  the 
extent  of  one  bicuspid  tooth,  the  treatment  clearly  indicated  is  to 
extract  the  first  lower  bicuspid  on  the  abnormal  side  and  diminish 
the  size  of  the  arch  by  the  complete  retraction  of  the  cuspid  and 
disto-lingual  movement  of  the  incisors,  which  may  be  readily  ac- 
complished by  a  combination  of  stationary  and  occipital  anchorage, 
as  in  Fig.  262,  operated  on  the  lower  arch.  The  Baker  form  of 
anchorge  may  be  often  advantageously  employed  to  assist  the 
devices  in  the  various  plans  of  treatment  in  both  division  and  sub- 
division of 


280  MALOCCLUSION. 

CHAPTER   XXI. 

TECHNIQUE. 

IN  the  study  of  orthodontia,  in  addition  to  the  lectures  of  the 
general  course,  which  should  be  full  and  complete,  covering  all 
phases  of  the  subject  (including  its  relations  to  rhinology  and  com- 
parative anatomy)  and  being  freely  illustrated  by  charts  and  pro- 
jections upon  the  screen,  we  would  suggest  the  great  advisability 
of  giving  a  short  course  of  instruction  in  the  technique.  It  should 
begin  with  lessons  in  soldering  by  the  method  we  have  described 
in  the  chapter  embracing  that  subject.  The  student  should  be 
taught  to  unite  various  lengths  of  the  ligature  and  G  wires,  end  to 
end  and  at  various  angles,  as  well  as  in  the  form  of  delicate  staples, 
hooks,  loops,  and  ferrules,  cultivating  delicacy  of  touch  and  steadi- 
ness in  holding  the  wires  with  the  fingers  in  the  operation.  The 
proper  amount  of  flux  and  solder  to  be  used  should  also  be  consid- 
ered, as  well  as  the  proper  degree  and  direction  of  flame  best  suited. 
After  sufficient  instruction  in  the  manipulating  and  soldering 
of  wire  by  means  of  both  hard  and  soft  solder,  instructions  may  be 
carried  further  to  the  making  of  the  plain  bands  upon  teeth  the 
roots  of  which  have  been  imbedded  in  plaster,  with  variations  in 
the  positions  of  the  seam,  and  to  the  careful  formation  of  the  few 
standard  combinations  of  the  system. 

The  course  should  also  embrace  careful  instruction  in  impres- 
sion and  model  making,  as  well  as  the  full  discussion  and  diag- 
nosis of  conditions  in  actual  cases  according  to  the  classification 
of  malocclusion,  the  variation  from  the  normal  of  the  facial  lines, 
the  tracing  of  causes,  etc. 

Such  a  course  could  be  made  very  attractive  to  the  class.  In- 
terest in  the  subject  would  be  deepened  by  the  spirit  of  rivalry 
that  would  be  aroused  and  by  the  better  comprehension  of  princi- 
ples that  would  result  from  the  object  lessons. 

Not  until  the  completion  of  this  course,  conducted  with  con- 
siderable thoroughness,  should  the  plans  of  treatment  be  dis- 
cussed and  the  application  of  appliances  and  their  operation  be 
attempted. 


GENERAL    SUGGESTIONS.  28 1 

CHAPTER   XXII. 

GENERAL   SUGGESTIONS. 

I.  AN  essential  preliminary  to  the  treatment  of  a  case  is  a  clear 
conception  of  what  is  necessary.     This  can  be  acquired  only  by  a 
careful  study  of  models  and  natural  teeth,  occlusion,  and  facial 
expression,  history,  etc. 

II.  If  a  malposed  tooth  be  crowded  by  other  teeth  no  tension 
should  be  exerted  upon  it  until  their  pressure  shall  have  been  re- 
leased by  their  partial  movement,  which  should  continue  during 
the  process  somewhat  in  advance  of  the  movement  of  the  tooth  they 
would  otherwise  obstruct. 

III.  One  of  the  essentials  of  success  of  treatment  is  the  full 
and  cordial  co-operation  of  patient,  parents,  and  operator,  whose 
instructions  should  be  clear  and  explicit  as  to  the  part  they  are 
expected  to  perform.     At  the  beginning  definite  understanding 
should  be  had  as  to  times  of  visits  by  the  patient.     A  few  minutes 
two  or  three  times  per  week  should  be  devoted  to  each  case.     Both 
patient  and  operator  should  observe  these  appointments  with  the 
utmost  conscientiousness.     Dereliction  in  this  respect  at  any  stage 
of  treatment  might  necessitate  a  repetition  of  work  and  bring  about 
various    annoying    complications.     This    matter    cannot    be    too 
strongly  impressed. 

IV.  Carefulness,   thoroughness,   and   promptness   of   decision 
and  action  at  each  visit  of  the  patient  are  imperative,  doing  exactly 
what  is  clearly  indicated  without  deferring  until  another  time.     If 
an  arch  is  to  be  changed  in  form,  anchorage  shifted,  an  over- 
twisted  ligature  to  be  renewed,  a  different  attachment  added  to  a 
band,  a  band  replaced,  removed,  or  a  new  one  added,  etc.,  it  should 
be  done  promptly,  only  dismissing  the  patient  after  knowing  with 
the  fullest  confidence  that  each  and  every  part  of  the  regulating  ap- 
pliance is  fully  performing  the  object  for  which  it  was  applied.    In 
order  to  accomplish  this  it  is  essential  that  there  be  a  ready  supply 
of  appliances  sufficient  to  meet  all  requirements. 

V.  Exercise  such  care  and  judgment  in  the  adjustment  of  the 
appliances  that  delays  from  slipping,  breaking,  or  changes  will  be 
avoided. 


282  MALOCCLUSION. 

VI.  In  moving  a  tooth,  the  best  result  is  obtainable  only  by 
recognizing  the  regular  and  prompt  amount  of  force  necessary  to 
stimulate  absorption.     The  practice  of  applying  great  force  at-  ir- 
regular intervals  serves  only  to  defeat  the  desired  object,  for  it 
retards  absorption  and  restoration,  causes  unnecessary  pain,  ex- 
cites   inflammation,    and    thereby    endangers    pulp-life.     It    also 
strains  the  appliances,  causing  much  delay  and  pain  to  the  patient 
by  repairs.     The  pressure  should  in  no  instance  be  greater  than 
will  cause  a  snug  feeling,  which  is  a  true  indication  of  the  proper 
degree  of  force. 

VII.  It  should  not  be  forgotten  that  the  correction  of  irregu- 
larities in  one  arch  only  cannot  be  a  success  unless  the  teeth  of 
the    opposite    arch    properly    occlude    with    them.     The    author 
urgently  insists  that  both  arches  must  be  considered  in  the  treat- 
ment of  even  the  simplest  cases. 

VIII.  The  cleansing  of  teeth  and  appliances  during  move- 
ment is  very  important;  but  as  the  brush  might  disarrange  the 
appliances,  the  cleansing  should  be  effected  by  frequent  rinsing 
with  water  and  antiseptic  solutions. 

IX.  The  author  hopes  to  impress  two  points  upon  those  who 
study  this  book.     First,   the  importance  of  occlusion,  in  which 
he  would  arouse  a  keener  interest.     Second,  the  relation  that  each 
tooth  bears   to  all  others  in  both  arches,  that  there  may  always  be 
careful  deliberation  before  sacrificing  a  tooth.     The  consequences 
of  extraction  of  even  a  single  tooth  are  often  far-reaching,  and 
sometimes  make  impossible  the  attainment  of  results  which  other- 
wise might  closely  approach  the  ideal.     All  dentists  should  culti- 
vate the  habit  of  observing  the  results  following  the  extraction  in 
the  cases  of  patients  in  their  regular  practice. 

X.  Malocclusion  in  any   degree,   however  slight,   should  be 
promptly  corrected.     An  overlapping  or  twisted  tooth  is  often  a 
blemish  in  an  otherwise  faultless  arrangement.     Its  adjustment 
would  not  only  improve  the  appearance  of  the  teeth,  but  would 
refine  the  whole  facial  expression. 

XL  In  tooth  movement  study  to  avoid  the  recession  of  teeth 
as  much  as  possible.  The  movement  may  be  suspended  as  often 
as  may  be  necessary  if  the  positions  of  the  teeth  be  maintained. 
Disregard  of  this  principle,  usually  due  to  faulty  appliances  whose 
frequent  removal  for  modification  and  cleansing  was  necessary,  has 


GENERAL    SUGGESTIONS.  283 

been  the  occasion  of  nearly  all  the  pain  and  soreness  incident  to 
regulating.  If  intelligently  conducted,  the  movement  of  a  tooth 
will  be  nearly  painless. 

XII.  Thorough  familiarity  with  all  the  parts  of  this  system  of 
appliances,  their  names  and  uses,  is  very  desirable  to  any  operator 
who  may  adopt  it.     They  will  be  found  sufficient  for  the  treatment 
of  any  case.     If  any   apparent   difficulty   should   arise  it   would 
probably  be  made  clear  by  a  rereading  of  the  descriptions  and  uses 
of  the  parts  and  the  treatment  of  analogous  cases. 

XIII.  The  plate  has  no  place  in  this  system  except  rarely  as  a 
retainer  after  lateral  expansion  of  the  arch.     As  a  regulating  ap- 
pliance it  should  be  regarded  with  respect  only  as  a  relic  of  the 
infancy  of  orthodontia. 

XIV.  The  gag,  in  whatever  style  of  contrivance,  is  a  medieval 
survival, — an  utterly  valueless  instrument.     During  the  period  of 
tenderness  the  patient  will,  without  admonition,  exercise  all  care  in 
occlusion  that  will  be  necessary  to  avoid  interference  with  the  move- 
ment of  teeth. 

XV.  Failure  to  appreciate  the  artistic  opportunities  and  re- 
quirements in  the  practice  of  orthodontia  is  as  readily  recognizable 
as  its  effect  is  lasting.     All  who  hope  to  attain  true  success  in 
practice  should  cultivate  studious  observation  of  normal  and  ab- 
normal facial  lines  in  their  relation  to,  and  dependence  upon,  the 
teeth.     The  line  of  harmony  as  laid  down  in  the  chapter  on  Facial 
Art  is  an  excellent  guide  in  this  respect.     An  intelligent  apprecia- 
tion of  the  principles  of  art  as  related  to  orthodontia  and  their 
conscientious  application  must  ever  go  hand  in  hand  with  real 
success  in  its  practice. 

XVI.  In  studying  a  case  of  malocclusion,  give  no  thought  to 
appliances  or  methods  of  treatment  until  the  case  shall  have  been 
classified  and  all  peculiarities  and  variations  from  the  class  type 
thoroughly    understood.     Then    consider   appliances,   anchorage, 
and,  finally,  possibilities  of  requirement  as  to  extraction. 

XVII.  While  the  primary  purpose  of  this  work  is  to  arouse  a 
keener  interest  in  orthodontia  on  the  part  of  the  dental  profession, 
yet  to  expect  that  all  will  succeed  in  its  practice  would  be  as 
unreasonable  as  to  expect  all  to  succeed  in  the  study  of  music. 
Expert  knowledge  and  skill  in  the  general  practice  of  dentistry  are 
compatible  with  very  little  study  of  orthodontia,  the  practice  of 


284  MALOCCLUSION. 

which  should  be  confined  to  those  who  possess  such  aptitude  and 
fondness  for  it  as  will  lead  them  to  study  it  broadly  and  enthusiasti- 
cally. Those  dentists  who  find  this  uncongenial  should  feel  it  in 
no  sense  an  infraction  of  their  professional  dignity  to  refer  cases 
which  come  to  their  notice  to  specialists  in  whom  they  have  con- 
fidence, as  broad-minded  physicians  and  surgeons  now  take  pleas- 
ure in  referring  unfamiliar  cases  to  those  specially  qualified  to 
treat  them.  The  procedure  serves  to  increase  the  patient's  confi- 
dence in  the  integrity  of,  and  heightens  his  esteem  for,  the  prac- 
titioner, who  is  not  expected  to  possess  all  knowledge.  On  the 
other  hand,  any  evasive  temporizing  or  unscientific  treatment 
must  inevitably  result  in  dissatisfaction  and  derogatory  criticism. 
All  should  feel  a  sense  of  satisfaction  in  the  upbuilding  of  so 
beneficent  a  science, — a  science  which  is  destined  to  supply  a  cry- 
ing need  of  humanity,  and  which  must  find  its  highest  develop- 
ment in  special  practice. 

XVIII.  Irregularities  of  the  teeth  being  so  frequently  associated 
with  some  pathological  obstruction  of  !the  nasal  passages  or  naso- 
pharynx, this  fact  should  ever  be  present  in  the  operator's  mind 
and  suitable  examination  be  made;  and  in  case  (as  is  often  found) 
the  oral  deformity  be  complicated  by  the  presence  of  hypertrophied 
faucial  tonsils,  adenoid  hypertrophies  in  the  vault  of  the  pharynx, 
or  obstruction  of  the  nasal  passages,  the  orthodontist's  work  can 
only  be  made  complete  by  the  assistance  of  the  rhinologist  and 
laryngologist. 

XIX.  In  conclusion,  to  all  who  have  derived  any  knowledge 
or  inspiration  from  this  book  is  commended  the  advice  of  Sir 
Andrew  Clark  to  readers  of  any  book  deemed  worthy  of  attention, 
—read  it  three  times.     "First,  to  see  what  it  is  all  about;  second, 
to  see  what  it  says ;  third,  read  it  in  an  attitude  of  friendly  hostility." 


PART  II. 
FRACTURES  OF  THE  M AXILLA. 


TREATMENT. 

FRACTURES  of  the  maxillae  may  result  from  any  of  the  numerous 
forms  of  violence  and  accident.  Indeed,  it  would  seem  that  the 
tendency  of  modern  customs  of  civilization,  with  their  necessity 
for  increase  in  methods  of  travel,  are  promotive  of  increase  of 
accidents  and  fractures.  The  common  occurrence  of  fracture 
of  the  maxilla  should  incite  us  to  look  for  more  efficient  means  of 
treatment  than  have  heretofore  prevailed,  and  dentists  may  well 
devote  a  closer  study  to  this  branch  of  practice. 

The  limits  of  this  work  will  not  admit  of  a  general  discussion  of 
this  subject,  nor  is  it  deemed  necessary,  for  all  the  modern  works 
on  general  surgery  contain  treatises  covering  the  general  prin- 
ciples of  treatment;  especially  commendable  is  Hamilton  on  Frac- 
tures. Our  chief  purpose  is  to  treat  of  methods  of  reduction  and 
fixation. 

While  fractures  of  the  superior  maxilla  occasionally  occur,  yet 
they  are  far  less  common  than  fractures  of  the  inferior  maxilla, 
and  are  usually  less  troublesome  to  manage,  for  if  the  fractured 
portions  be  placed  in  apposition  they  require  little  support,  owing 
to  the  immobility  of  the  bone;  while  the  mobility  of  the  inferior 
maxilla  and  the  many  causes  which  tend  to  displace  it,  such  as 
swallowing,  speaking,  coughing,  sneezing,  hiccoughing,  etc.,  make 
it  far  more  difficult  to  support.  Indeed,  Hamilton  has  well  said, 
"Of  all  fractured  bones  surgeons  are  called  upon  to  treat,  none  are 
so  troublesome  as  the  inferior  maxilla." 

Although  fractures  may  occur  in  any  part  of  the  bone,  the  most 
favorable  locality  is  the  body,  in  the  region  of  the  cuspid  or  the 

285 


286  MALOCCLUSION. 

second  bicuspid.  The  next  most  favorable  locality,  in  the  author's 
experience,  is  in  the  region  of  the  third  molar;  rarely  in  the  ascend- 
ing ramus,  probably  owing  to  its  strong  encasement  of  muscles; 
still  more  rarely  in  the  condyloid  process;  occasionally  in  juxta- 
position to. the  symphysis.  Where  the  blow  is  severe  a  double 
fracture  usually  occurs,  often  being  in  such  cases  in  the  region 
of  the  cuspid  on  one  side  and  of  the  first  molar  on  the  other. 

In  fracture  of  the  jaw  there  is  a  tendency  to  displacement,  as 
in  cases  of  fracture  of  the  long  bones,  owing  to  the  stimulated  mus- 
cular contraction.  If  in  the  body  of  the  bone  or  at  the  angle, 
the  digastric,  the  genio-hyoid,  and  the  genio-hyo-glossus  muscles 
tend  to  draw  the  anterior  segment  down  and  back,  while  the 
muscles  of  mastication  tend  to  draw  upward  and  close  the  posterior 
segments  and  to  occlude  the  teeth.  By  studying  these  muscles 
we  may  often  take  advantage  of  their  tendencies  to  assist  in  the 
support  of  the  fracture.  In  the  treatment  of  fractures  our  aim 
should  be  toward  two  principal  ends:  first,  to  so  set  and  support 
the  jaw  that  the  result  will  be  a  restoration  of  former  conditions, 
as  indicated  by  the  natural  occlusion  of  the  teeth  peculiar  to  each 
case ;  second,  to  support  the  bone  in  its  normal  position  as  immov- 
ably as  possible.  It  is  well  known  that  if  the  bone  be  immovably 
supported,  usually  about  twenty-one  days  will  be  sufficient  for  its 
retention,  although  the  locality  and  extent  of  fracture  may  require 
the  prolonging  of  this  period  considerably.  Again,  it  is  well 
known  that  the  tendency  to  sepsis  is  far  less  if  the  bone  be  firmly 
supported  than  if  occasional  movement  at  the  points  of  apposi- 
tion be  permitted.  If  the  fractured  portions  of  bone  be  placed  in 
careful  apposition  the  degree  of  force  necessary  to  prevent  dis- 
placement is  usually  small  and  does  not  necessitate  strong  or  bulky 
devices,  but  only  requires  that  the  device  be  intelligently  propor- 
tioned and  placed. 

The  history  of  the  different  methods  of  securing  fixation  is  in- 
teresting, as  well  as  surprising,  as  to  the  bulk  of  some  and  the  com- 
plexity of  others.  Be  it  said  to  the  credit  of  dentists  that  the 
methods  possessing  the  greatest  merit  and  the  most  nearly  in  ac- 
cordance with  the  scientific  requirements  have  been  their  inven- 
tions. Plans  usually  employed  by  the  general  surgeon  are  as 
crude  and  unscientific  as  they  are  ancient  in  history.  This  is  but 
natural  when  we  remember  that  the  requirements  in  the  support 


FRACTURES   OF   THE    MAXILLA.  287 

of  the  maxilla  are  very  different  from  those  in  the  support  of  other 
bones,  and  necessitate  devices  which  the  general  surgeon  cannot 
readily  construct  with  his  facilities.  The  three  methods  most  com- 
monly employed  by  surgeons  are,  first,  bandaging;  second,  tying 
the  teeth  together  with  ligatures;  third,  wiring  the  ends  of  the  bone 
together. 

History  records  the  use  of  the  first  since  the  fifth  century,  al- 
though it  was  doubtless  employed  ages  before,  as  it  is  a  means  of 
support  which  would  naturally  suggest  itself.  Yet  a  more  crude 
or  unscientific  method  of  contributing  support  to  a  fractured  jaw 
could  hardly  be  imagined.  In  the  first  place,  the  direction  and 
distribution  of  force  exerted  by  the  bandage  is  wholly  inadequate 
for  the  natural  requirements.  The  effect  of  the  combined  wrapping 
is  to  exert  force  from  the  dome  of  the  head,  or  in  the  wrong  direc- 
tion. It  must  be  remembered  that  the  natural  tendency  of  the 
fractured  jaw  is  backward  and  inward.  The  bandage  can  in  most 
instances  only  favor  this  tendency.  To  exert  force  in  the  requisite 
direction  it  should  be  applied  from  a  point  far  anterior  to  the 
forehead.  Another  disadvantage  is  the  frequent  displacement  of 
the  bandage.  It  is  a  fact  easily  verifiable  that  a  bandage  placed 
ever  so  skillfully  about  the  head  cannot  prevent  considerable  free- 
dom of  movement  of  even  an  uninjured  jaw,  to  say  nothing  of  the 
tmsightliness  of  it. 

The  second  plan,  that  of  wiring  or  ligating  the  teeth  together, 
was  practiced  by  Hippocrates  in  the  fifth  century  B.  C.,  and  is  a 
sad  commentary  on  the  progress  of  this  branch  of  surgery.  It 
is  so  crude  an  application  of  mechanics  that  it  is  surprising  that 
it  should  ever  be  resorted  to  in  the  present  day,  though  doubtless 
in  its  inception  it  was  an  improvement  on  the  then  prevailing 
methods  ;  for  it  will  either  slide  off  the  crowns  or  work  down  be- 
neath the  gums  and  lose  its  support,  as  well  as  cause  much  in- 
flammation of  the  gums  and  peridental  membrane  and  loosen  the 
teeth. 

The  wiring  of  the  ends  of  the  bone  together  can  at  best  only  form 
a  link  joint,  admitting  ef  movement.  The  natural  absorption  re- 
sulting from  pressure  of  the  wire  upon  the  bone  must  soon  lessen 
the  support,  and  frictional  irritation  and  suppuration  are  inevita- 
ble. The  infliction  of  irritating  wounds  on  each  side  of  the  one 
intended  to  be  healed  is  irrational,  and  is  as  inconsistent  with  the 


288  MALOCCLUSION. 

requirements  of  the  aseptic  surgery  of  the  present  day  as  it  is 
cruel  and  unnecessary.  While  the  fractured  ends  may  be  sup- 
ported by  some  form  of  intermaxillary  splint,  yet  this  is  bulky  and 
uncleanly,  and  is  objectionable  for  the  reason  that  it  keeps  the 
muscles  of  mastication  on  constant  tension. 

The  plans  of  fixation  devised  by  the  author  in  the  course  of  his 
practice  were  described  and  illustrated  in  the  fourth  edition  of  this 
work.  Since  its  publication  a  number  of  cases  have  been  treated 
by  him,  as  well  as  by  other  practitioners,  both  in  this  country  and 
Europe,  employing  the  methods  therein  set  forth,  with  results  so 
uniformly  satisfactory  as  to  confirm  his  belief  in  the  standard  value 
of  these  methods,  as  to  efficiency,  simplicity,  and  cleanliness. 

A  simple  and  reliable  guide  for  the  placing  of  the  fractured 
ends  of  the  bone  in  apposition  is  the  occlusion  of  the  teeth.  If  the  . 
jaws  are  closed  and  the  teeth  placed  in  their  natural  occlusal 
relations,  it  must  follow  that  the  ends  of  the  bone  are  in  correct 
apposition.  If  the  jaw  be  so  retained  it  will  be  in  the  most  favor- 
able position  for  nature's  work  of  repair.  The  natural  locking  of 
the  cusps  will  be  most  effectual  for  the  steady  support  of  the  injured 
jaw.  To  keep  the  jaw  closed  and  the  occlusal  planes  of  the  cusps 
in  harmony  we  have  but  to  firmly  connect  some  of  the  teeth  of 
both  arches  by  suitable  appliances  placed  upon  their  crowns,  their 
roots  forming  the  most  natural  and  most  stable  attachment  and 
support  for  the  fractured  segments  of  the  jaw;  or,  in  other  words, 
the  uninjured  jaw  is  made  to  act  as  a  splint  to  which  the  injured 
jaw  is  bound  by  means  of  its  firm  attachment  to  the  roots  of  the 
teeth. 

This  is  accomplished  by  holding  the  jaws  in  fixed  contact  by 
means  of  wire  ligatures  wrapped  in  the  form  of  the  figure  8  around 
buttons  attached  to  bands  encircling  suitable  opposite  or  nearly 
opposite  teeth,  as  shown  in  Fig.  285. 

The  bands,  which  we  term  fracture  bands,  Fig.  286,  are  made 
very  thin  but  strong;  they  are  adjustable,  and  by  means  of  the  screw 
and  nut  may  be  firmly  clamped  about  the  teeth.  Small  buttons, 
strong  and  of  sufficient  size  to  admit  the  requisite  number  of  wrap- 
pings of  the  ligatures,  are  firmly  soldered  to  the  band.  Care  should 
always  be  exercised  to  work  the  band  well  over  the  crown  of  the 
tooth  and  down  upon  its  neck,  then  to  tighten  the  nut  until  the 
band  is  firmly  clamped,  being  careful  not  to  weaken  it  by  crimping 


FRACTURES    OF    THE    MAXILLA.  289 

or  tearing.  The  fingers  alone  are  usually  sufficient,  although  a 
dull  instrument  and  mallet,  as  in  Figs.  73  and  74,  may  be  used  to 
assist.  If  the  teeth  be  crowded,  the  directions  given  in  Chapter  IX 
for  setting  clamp  bands  should  be  observed.  The  wire  ligatures, 
already  described  in  the  first  part  of  this  work,  are  best,  although 
fibrous  ligatures  may  be  used. 

FIG.  285. 


FIG.  286. 


Bicuspid.  Molar. 

That  the  reader  may  become  more  familiar  with  this  method  of 
treatment,  as  well  as  with  a  few  of  the  many  modifications  of 
which  it  is  susceptible,  reports  of  a  few  cases  from  practice  are 
subjoined,  with  illustrations  from  models  made  accurately  in  each 
instance  after  treatment. 

Case  I. — Fig.  -287*  On  July  14,  1889,  W.  F.,  aged  forty- 
five,  was  admitted  to  the  Minneapolis  City  Hospital.  A  blow  from 
a  policeman's  club  had  produced  one  simple  and  one  compound 
fracture  of  the  inferior  maxilla.  The  first  was  an  oblique  fracture 
of  the  right  side,  beginning  with  the  socket  of  the  second  bicuspid, 
extending  downward  and  backward,  and  involving  the  socket  of 
the  first  molar.  The  second  bicuspid  had  fallen  out,  and  the  first 
molar  was  much  loosened.  The  second  molar  had  been  lost  years 

*The  illustration  is  merely  historical.  Though  the  method  was  efficient,  it 
has  been  simplified  in  later  practice,  as  shown  in  'following  illustrations. 


290 


MALOCCLUSION. 


before,  while  the  third  molar  and  the  remaining  teeth  were  much 
abraded  and  much  loosened  by  salivary  calculus.  The  second  frac- 
ture was  on  the  opposite  side,  high  up  in  the  ramus  of  the  jaw.  1 
could  not  detect  the  exact  course  the  line  of  fracture  had  taken,  but 
the  crepitation  of  the  ends  of  the  bones  and  the  pain  occasioned 
thereby  were  unmistakable  evidences  of  fracture.  The  patient,  as 
is  usual  in  such  cases,  was  unable  to  close  his  jaws.  The  fractured 
parts  on  the  right  side  were  widely  separated,  and  the  anterior 
piece  much  depressed  by  reason  of  the  action  of  the  digastric  mus- 
cle, the  posterior  piece  of  bone  being  firmly  drawn  up  and  the 
molars  occluding  by  reason  of  the  contraction  of  the  masseter 
muscle.  He  was  treated  as  follows : 

Bands  were  made  to  encircle  all  four  of  the  cuspids  (they  being 
most  firmly  attached  in  their  sockets).  The  fractured  ends  of  the 
bones  were  placed  in  careful  apposition  and  the  lower  jaw  closed, 
the  lower  teeth  being  correctly  occluded  with  the  upper. 

FIG.  287. 


The  points  on  the  bands  where  the  little  tubes  (shown  in  the 
engraving)  should  be  attached  were  carefully  noted  and  marked. 
The  bands  were  slipped  off  and  the  tubes  soldered  to  them,  after 
which  the  bands  were  cemented  in  proper  position  upon  the  teeth 
and  two  small  traction  screws  (shown  in  the  engraving)  were  in- 
serted in  the  tubes.  The  jaws  were  closed,  and  the  nuts  tightened. 

During  an  attack  of  coughing  the  following  night  one  of  the 
bands  was  loosened,  but  it  was  easily  replaced  the  next  day.  No 
further  accident  or  trouble  occurred,  the  patient  readily  taking 
nourishment  through  the  spaces  between  the  teeth.  Thus  the  frac- 


FRACTURES    OF    THE    MAXILLAE. 


291 


tured  jaw  was  firmly  supported  without  motion  for  twenty-two 
days,  when  the  appliance  was  removed,  showing  most  excellent 
results. 

That  the  patient  was  a  great  lover  of  the  clay  pipe  is  shown  in 
the  engraving  by  the  much-worn  ends  of  the  lateral  incisors,  which 
resulted  from  holding  the  stem  of  the  pipe.  While  wearing  the 
appliance  he  was  not  debarred  from  his  favorite  enjoyment,  al- 
though compelled  to  grasp  the  stem  between  his  lips  instead  of  the 
teeth. 

Case  //.—December  28,  1889,  T.  B.  was  admitted  to  the  Dental 
Infirmary  of  the  University  of  Minnesota  suffering  from  the  effects 

FIG.  288. 


of  a  blow  received  on  the  left  side  of  the  jaw  from  a  cant  hook, 
while  working  in  a  lumber  camp.  The  result  was  two  fractures  of 
the  jaw. 

The  first  fracture  was  on  the  right  side,  beginning  between  the 
first  and  second  bicuspids,  and  extending  downward  and  backward 
so  far  as  to  involve  the  lower  part  of  the  anterior  root  of  the  first 
molar.  The  second  was  on  the  left  side,  directly  through  the  angle 
of  the  jaw,  Fig.  288.  The  accident  had  occurred  thirty-two  days 
previous  to  his  admission  to  the  infirmary,  during  which  time  noth- 
ing had  been  done  to  reduce  the  fracture.  He  reported  that  he 
had  called  upon  a  physician,  who  supposed  the  trouble  was  merely 
an  abscessed  tooth,  and  lanced  the  gum  with  a  view  of  reducing  the 
swelling.  Later  the  patient  called  upon  a  dentist  in  one  of  the 


292  MALOCCLUSION. 

smaller  towns,  who  also  failed  to  diagnose  the  fracture,  and  ex- 
tracted both  bicuspids  on  the  left  side  in  the  hope  of  giving  relief. 

Upon  examination  I  found  considerable  swelling  in  the  region  of 
the  fracture,  with  the  usual  results ;  the  patient  was  unable  to  close 
his  mouth,  by  reason  of  the  anterior  piece  of  the  fractured  bone 
being  drawn  down  by  the  depressor  muscles.  A  false  joint  had 
also  become  established,  and  could  be  easily  moved  without  causing 
pain.  At  the  fracture  of  the  right  side  there  was  but  little  displace- 
ment ;  the  swelling  was  also  slight. 

The  patient  was  anesthetized,  and,  with  a  view  to  breaking  up 
the  false  attachments  and  stimulating  activity  in  repair,  the  ends 
of  the  bone  were  rubbed  forcibly  together,  placed  in  perfect  appo- 
sition, and  the  jaw  closed,  great  care  being  taken  to  occlude  the 
teeth  correctly  according  to  their  former  relations.  The  jaw  was 
now  firmly  bound  in  position  as  described  on  page  288  and  shown 
in  Fig.  288,  the  attachment  being  quite  as  efficient  and  much  easier 
to  adjust  than  that  shown  in  Fig.  287.  Four  bands  were  used, 
encircling  the  four  cuspids,  as  shown  in  the  engraving.  The  bands 
shown  on  the  molars  were  not  used,  as  they  were  found  to  be  un- 
necessary, since  the  jaws  were  firmly  supported  by  the  four  anterior 
bands  alone.  The  patient  made  a  rapid  recovery,  the  bands  being 
removed  on  the  twenty-first  day. 

Case  III,  represented  by  Fig.  289,  was  that  of  a  healthy  young 
Swede,  twenty-two  years  of  age,  who,  while  washing  windows,  had 
fallen  from  the  second  story  to  the  pavement.  Besides  receiving 
several  minor  injuries,  he  sustained  two  fractures  of  the  lower  jaw ; 
one  extending  from  between  the  central  incisors,  and  one  posterior 
to  the  second  molar,  the  third  molar  having  been  extracted.  The 
right  superior  lateral  and  cuspid  were  knocked  out,  the  first  bi- 
cuspid broken  off  near  the  neck,  and  the  alveolar  process  badly 
shattered.  The  centrals  and  left  lateral  were  bent  inward  and 
forced  deeper  into  their  sockets.  He  had  been  treated  by  the  at- 
tending physician  at  the  City  Hospital,  the  method  employed  being 
that  of  the  Barton  style  of  bandaging,  with  the  usual  result,  when 
the  bandage  is  employed  in  such  cases,  of  aggravating  the  condi- 
tion by  forcing  the  pieces  inward  and  the  jaw  backward. 

Upon  examination  three  weeks  after  the  accident,  I  found  much 
displacement.  The  jaw  was  drawn  backward,  and  the  right  middle 
section  of  the  bone  tipped  inward.  No  attention  had  been  paid  to- 


FRACTURES   OF   THE    MAXILLAE.  293 

the  bent  and  broken  condition  of  the  superior  alveoli.  The  teeth 
had  become  quite  firm  in  their  new,  but  abnormal,  positions,  and  I 
allowed  them  to  remain  so.  A  fibrous  attachment  had  been  estab- 
lished in  the  lower  fracture,  which  admitted  of  considerable  move- 
ment and  occasioned  but  little  pain.  There  was  much  swelling, 
and  pus  was  discharging  into  the  mouth  from  the  anterior  fracture. 
I  found  it  impossible  to  restore  normal  occlusion  at  that  time. 
Bands  were  made  to  encircle  the  four  bicuspids,  and  between  the 
two  lower  bands,  on  the  inside  of  the  mouth,  was  placed  one  of  the 

FIG.  289. 


jack-screws  E  and  J,  held  in  place  by  the  staple  and  spur  B,  Fig.  100, 
and  E,  Fig.  101.  The  nut  was  tightened  until  the  piece  of  bone 
had  been  tipped  outward  about  one-half  the  distance  to  its  normal 
position,  but  the  operation  caused  so  much  pain  that  further  move- 
ment was  deferred.  The  jaws  were  then  closed  and  the  buttons 
connected  by  ligatures,  but  occlusion  was  far  from  being  normal. 
On  the  next  day,  by  again  tightening  the  nut  on  the  jack-screw  and 
with  renewed  ligatures  bound  very  tightly,  I  was  enabled  to  secure 
nearly  the  normal  occlusion.  On  the  third  day  following,  by  the 
same  means,  correct  occlusion  was  established.  The  jack-screw 
was  allowed  to  remain  in  position  to  steady  the  tipping  section. 

The  abscess  was  frequently  syringed  with  fresh  peroxid  of 
hydrogen.  A  few  fragments  of  bone  were  washed  out.  The  frac- 
tures readily  united,  and  on  the  twenty-seventh  day  the  jaw  was 
released  and  found  to  be  quite  firm. 


294 


MALOCCLUSION. 


Case  IV  shows  another  modification,  and  is  represented  by  Fig. 
290.  A  young  machinist  received  a  severe  blow  from  the  fist  of 
an  antagonist,  by  which  two  compound  fractures  were  sustained ; 
one  posterior  to  the  first  molar,  the  other  in  the  region  of  the  cuspid, 
which  was  involved  and  greatly  loosened. 

Occlusion  was  established  in  the  previously  described  way. 
Suppuration  occurred  in  both  fractures  on  about  the  tenth  day,  and 
received  proper  treatment.  The  union  of  the  anterior  fragment 
was  slow,  as  the  patient  was  troubled  by  a  persistent  hacking  cough, 
which  occasioned  a  slight  movement  between  the  ends  of  the  bone, 
just  sufficient  to  interfere  with  the  healing  process.  On  the 

FIG.  290. 


twentieth  day  the  ligatures  were  cut,  a  jack-screw  placed  in  posi- 
tion between  the  bands  on  the  inside  in  the  same  manner  as  in  the 
case  last  described,  with  an  additional  ligature  firmly  connecting 
the  two  buttons  on  the  lower  bands  and  resting  in  contact  with  the 
labial  surfaces  of  the  intervening  teeth.  This  additional  support 
proved  successful ;  the  union  proceeded  slowly,  and  was  found  com- 
plete when  the  bands  were  removed  on  the  sixty-second  day  after 
the  accident. 

Another  modification  is  shown  in  a  somewhat  peculiar  case, 
represented  in  Fig.  291.  The  patient,  a  man  about  forty  years 
of  age,  had  sustained  a-  complete  fracture  of  the  left  angle  of  the 
jaw,  as  the  result  of  a  kick  from  a  horse.  The  jaw  was  enormously 
large  and  protruding,  and  the  occlusion  so  unusually  faulty  that  I 


FRACTURES    OF    THE    MAXILLAE. 


295 


was  at  a  loss  to  determine  what  the  patient's  natural  occlusion  was ; 
but,  upon  questioning  him,  he  informed  me  that  when  a  boy  ten 
years  of  age  he  had  been  hit  with  a  stone,  causing  a  fracture  on  the 
right  side  of  the  jaw,  which  had  been  allowed  to  heal  without  any 
treatment.  This  statement,  with  the  worn  facets  upon  the  cusps  of 
some  of  the  teeth  and  the  readiness  with  which  they  occluded  only 
at  these  points,  showed  conclusively  the  position  in  which  the  jaw 
must  be  secured.  I  at  first,  of  course,  supposed  that  the  usual 
number  of  four  bands  and  two  ligatures  would  be  necessary,  but  I 
found  the  single  ligature,  as  shown,  was  quite  sufficient  to  firmly 
retain  the  jaw  in  this  abnormal  position.  The  jaw  was  set  a  few 


FIG.  291. 


hours  after  the  accident.  Very  little  swelling  ensued,  the  fractured 
parts  uniting  rapidly.  I  saw  the  patient  but  four  times,  and  re- 
moved the  bands  on  the  twentieth  day,  as  further  support  seemed 
unnecessary.  I  admonished  the  patient,  however,  to  avoid  using 
his  jaw  as  much  as  possible  for  at  least  ten  days  thereafter. 

Fig.  292  represents  a  case  where  the  patient  suffered  in  a  railroad 
wreck  two  compound  fractures  of  the  inferior  maxilla,  one  on  each 
side,  posterior  to  the  second  molar.  The  left  side  was  quite  badly 
comminuted.  The  full  complement  of  teeth  was  present,  with  the 
exception  of  the  third  molars,  and  the  occlusion  of  the  teeth  was 
close.  The  incisors,  however,  were  crossed  (not  well  shown  in 
this  engraving)  ;  that  is,  the  left  superior  central  and  lateral  closed 
just  inside  of  the  points  of  the  lower  incisor  and  cuspid,  while  the 


296 


MALOCCLUSION. 


right  central  and  lateral  closed  just  outside  of  the  points  of  the 
opposing  lower  cuspid,  central,  and  lateral. 

The  teeth  being  so  perfect  and  the  spaces  nearly  closed,  liquid 
foods  only  were  possible.  The  conditions  were  made  more  un- 
favorable on  account  of  the  patient's  suffering  from  severe  spinal 
injury  received  at  the  time  of  the  accident,  but,  with  the  exception 
of  considerable  suppuration  in  the  left  fracture,  which  yielded 
readily  to  treatment,  nothing  unusual  occurred.  The  ligatures 
were  removed  on  the  fortieth  day,  and  excellent  results  were  ap- 
parent. 

FIG.  292. 


It  might  be  urged  against  a  method  of  treatment  which  involves 
the  closure  of  the  teeth  and  the  binding  of  the  jaws  firmly  together 
that  the  patient  would  be  unable  to  take  sufficient  nourishment. 
Experience,  however,  shows  that  this  argument  has  practically  no 
foundation,  for  it  rarely  happens  that  a  patient  is  found  without 
some  missing  teeth,  thereby  providing  abundant  opportunity  for 
the  ingestion  of  all  ordinary  chopped  foods,  and  more  especially 
for  the  large  number  of  foods  now  available  in  liquid  form.  Even 
when  all  the  teeth  are  sound  and  in  perfect  condition,  there  is  plenty 
of  space  between  the  teeth,  or  behind  the  molars  and  between  the 
upper  and  lower  incisors,  for  taking  all  the  nourishment  necessary. 
Of  course,  in  these  rare  cases  more  time  would  be  required  for 
taking  nourishment.  This  inconvenience  is  very  slight  when  we 
consider  the  advantages  of  freedom  from  an  uncleanly,  bulky,  and 
inconvenient  apparatus  within  the  mouth,  often  accompanied  by 
the  disfigurement  of  bandages  and  splints  without,  as  well  as  the 


FRACTURES   OF   THE    MAXILLJE.  297 

great  importance  of  the  accuracy  in  results  which  it  assures,  so 
uncertain  of  attainment  in  many  other  methods  commonly  em- 
ployed. 

There  is  also  another  class  of  lesions  in  the  treatment  of  which 
this  plan  of  fixation  may  be  employed  to  great  advantage.  I  refer 
to  excision  of  the  lower  maxilla,  or  those  cases  where  a  large  por- 
tion of  the  jaw  has  been  removed,  as  in  Fig.  293. 

In  all  these  cases  there  is  a  strong  tendency  for  the  remaining 
portion  of  the  jaw  to  be  drawn  greatly  to  one  side  (about  three- 
quarters  of  an  inch,  by  actual  measurement,  in  the  case  repre- 
sented), due  to  the  contraction  of  the  cicatricial  tissues  following 


FIG.  293. 


the  healing  of  the  wound.  The  plan  I  propose  will  prevent  this 
contraction  by  securing  the  remaining  portion  of  the  jaw  in  proper 
occlusion,  by  means  of  the  fracture  bands  and  ligatures  in  the  man- 
ner already  described.  The  jaw  thus  firmly  held  will  exert  suffi- 
cient tension  upon  the  healing  muscles  to  prevent  their  contraction. 
I  would  also  suggest  the  advisability  of  increasing  the  tension  by 
the  attachment  of  a  plumper,  by  means  of  a  clamp  band,  to  one  of 
the  molars  in  the  upper  jaw  on  the  side  from  which  the  section  has 
been  removed,  allowing  the  shield  or  plumper  to  extend  downward 
and  outward,  to  occupy  somewhat  the  position  of  the  missing  bone. 
This  shield  may  also  serve  a  useful  purpose  in  holding  in  better 
position  the  dressing  of  the  wound. 

Another  method  may  be  said  to  be  a  modification  of,  or  an  im- 
provement upon,  the  plan  advocated  by  Hippocrates, — that  of 


298 


MALOCCLUSION. 


holding  the  fractured  ends  of  the  bone  in  apposition  by  wrapping 
ligatures  about  the  teeth,  or,  as  physicians  now  term  it,  wiring  the 
teeth. 

The  plan  I  propose  is  shown  in  Fig.  294,  and  consists  in  encir- 
cling suitable  teeth  with  fracture  bands  and  attaching  ligatures  to 
the  buttons  on  both  sides  of  the  bands,  so  that  loosening  of  the 
bones  or  pressure  upon  the  gums  is  impossible. 

FIG.  294. 


FIG.  295. 


A  modification  of  the  plan  is  shown  in  Fig.  295,  in  which  addi- 
tional support  is  secured  by  connecting  the  labial  and  lingual  wire 
ligatures  by  loops  of  wire  passed  between  the  teeth,  with  their  ends 
united  by  twisting. 

In  favorable  cases,  as  in  simple  transverse  fractures  with  little  or 
no  displacement,  and  where  the  teeth  are  very  firm,  if  the  apparatus 
be  adjusted  with  skill  the  plan  will  be  found  valuable,  as  it  is  very 


FRACTURES    OF   THE    MAXILLA. 


299 


neat,  clean,  and  compact,  and  does  not  interfere  with  the  freedom  of 
movement  of  the  jaw. 

A  few  suggestions  may  assist  the  inexperienced  in  the  adjust- 
ment of  the  apparatus,  so  that  it  will  surely  afford  equal  pressure 
and  support  upon  the  intervening  teeth.  The  only  difficulty  is  in 
regard  to  the  proper  length  of  the  lingual  ligature  when  completed. 
This  is  easily  overcome  by  using  two  small  soft  brass  wires,  pass- 
ing respectively  above  and  below  the  buttons  and  extending  beyond 
them  a  half-inch  or  more  at  each  end.  Tension  is  not  exerted  on 
the  buttons  by  uniting  the  ends  by  twisting  until  after  the  external 
and  transverse  ligatures  have  been  completed.  The  engraving  is 
incorrect  in  the  respect  that  only  one  end  of  the  lingual  ligature 
shows  union  of  the  ends,  instead  of  both. 

FIG.  296. 


Fig.  296  represents  a  modification  of  this  plan  used  for  holding 
in  position  a  large  section  of  the  alveolus,  including  the  incisors 
and  left  cuspid,  which  had  been  broken  outward  as  the  result  of 
falling  from  a  sled  while  coasting  with  the  knotted  end  of  a  rope 
held  in  the  mouth.  The  second  bicuspids  were  banded,  and  a  wire 
ligature  made  to  encircle  the  buttons  and  bear  against  the  loosened 
teeth.  The  ligatures  showed  a  slight  tendency  to  slide  down  and 
impinge  upon  the  gum,  but  this  was  easily  remedied  by  encircling 
the  main  ligature  and  the  incisors  with  two  or  three  fine  wire  liga- 
tures, thus  giving  additional  support  in  a  downward  direction. 

Fig.  297  shows  another  plan  for  securing  fixation  of  anterior 
fractures  which  possesses  several  valuable  features,  being  especially 
useful  in  cases  of  comminution  or  of  several  fractures  in  the  same 
vicinity.  Its  chief  excellence  lies  in  the  permission  of  free  move- 
ment of  the  jaws  while  firmly  retaining  the  fracture,  and  it  is  also 


300 


MALOCCLUSION. 


very  clean  and  compact.  The  device  is  a  thin  metal  cap,  swaged 
to  fit  the  crowns  accurately  and  covering  a  sufficient  number  of  the 
teeth  to  afford  the  necessary  support,  the  whole  being  firmly 
cemented  to  the  teeth  with  oxyphosphate  of  zinc.  Copper,  gold, 
silver,  aluminum,  or  vulcanite  may  be  used;  my  preference  is 
aluminum.  Considering  the  simplicity  of  this  appliance  and  the 
familiarity  of  dentists  with  oxyphosphate  of  zinc,  it  is  surprising 
that  the  value  of  this  idea  of  treating  fractures  has  not  before  been 
recognized;  but  I  find  no  record  of  its  use,  although  dentists  fre- 
quently use  similar  splints  in  the  retention  of  teeth  after  they  have 

FIG.  297. 


been  regulated,  and  Hullihen  employed  a  similar  device  in  1848  to 
hold  the  section  of  a  jaw  after  a  surgical  operation,  using  ligatures 
to  keep  the  appliance  in  place. 

For  several  years  I  supposed  I  had  been  the  first  to  employ  this 
method  of  retaining  fractures,  but  I  have  since  learned  that  Sir 
Christopher  Heath  attached  a  splint  for  the  retention  of  fractures 
in  a  similar  way,  using,  however,  softened  gutta-percha  (Heath  on 
Injuries  and  Diseases  of  the  Jaw,  third  edition),  and  Dr.  John  H. 
Martindale,  of  Minneapolis,  in  1886  or  1887,  cemented  a  Kingsley 
splint  in  position  to  avoid  the  use  of  the  submental  cap  and  ban- 
dages, which  interfered  with  the  treatment  of  wounds  on  the  face. 

My  first  case  treated  after  this  method  is  shown  in  Fig.  298. 
Michael  P.,  a  baker  by  trade,  had  fallen  down-stairs,  knocking  out 


FRACTURES    OF    THE    MAXILLA. 


301 


the  superior  incisors,  cuspids,  and  one  bicuspid,  also  loosening  the 
lower  central  incisors  and  fracturing  the  jaw  at  the  symphysis. 
As  I  remember,  he  also  received  a  fracture  of  one  of  the  femurs. 
He  was  admitted  to  the  Minneapolis  City  Hospital  some  time  in 
June,  1888.  I  saw  him  first  some  two  months  after  the  accident 
occurred,  during  which  time  the  attending  surgeon  had  employed 
the  Barton  style  of  bandaging  in  treatment.  Union  of  the  bone  had 
not  taken  place ;  on  the  contrary,  a  complete  fibrous  joint  had  been 
established,  with  the  ends  of  the  bone  more  or  less  rounded,  admit- 
ting of  a  free  hinge,  movement,  with  pus  discharging,  for  which  a 
large  rubber  drainage-tube  had  been  inserted.  The  tube  was  re- 

FIG.  298. 


moved,  the  wound  thoroughly  washed,  and  an  impression  taken 
without  any  attempt  at  changing  the  collapsed  condition  of  the 
sides  of  the  arch.  A  model  was  made  and  sawed  through  at  the 
point  of  fracture.  It  was  then  placed  in  the  articulator  and  ad- 
justed to  restore  the  original  occlusion  as  nearly  as  possible.  Over 
this  readjusted  model  a  very  thin  vulcanite  splint  was  formed, 
the  outlines  of  which  corresponded  to  the  dotted  lines  in  the 
engraving. 

The  first  attempt  at  cementing  it  in  position  upon  the  teeth  was 
unsuccessful,  the  cement  hardening  too  rapidly,  but  the  next  proved 
successful.  The  splint  remained  in  position  without  any  trouble 
for  nearly  four  months,  when  it  worked  loose,  and  I  found  upon 
examination  that  firm  union  had  taken  place. 


3O2  MALOCCLUSION. 

Of  course  the  range  of  usefulness  of  this  splint  is  quite  limited, 
as  a  sufficient  number  of  firm  teeth  must  be  present  on  each  side  of 
the  fracture.  Its  principal  value  will,  I  think,  be  found  in  treating 
fractures  in  the  anterior  part  of  the  jaw,  more  especially  in  that 
class  of  cases  resulting  from  gunshot  wounds  in  which  large  sec- 
tions of  the  alveolus  have  been  carried  away. 

Another  plan  which  I  have  used  in  a  few  favorable  cases  with 
much  satisfaction  is  shown  in  Fig.  299,  which  represents  my  first 
case  treated  by  the  method  in  question.  On  May  29,  1889,  a  young 
man  of  twenty-one  years  was  admitted  to  the  St.  Anthony  Hospital, 
of  Minneapolis.  During  an  attack  of  epilepsy  he  had  fallen  from  a 
lumber  pile  to  the  ground,  a  distance  of  fifteen  or  twenty  feet. 
Besides  receiving  severe  bruises,  he  sustained  a  compound  fracture 

FIG.  299. 


at  the  symphysis,  terminating  in  front  between  the  central  and 
lateral,  as  shown  by  the  line  in  the  engraving.  The  fractured  bone, 
when  first  seen,  was  quite  widely  separated  at  the  top,  and  the  left 
central  incisor  was  much  loosened.  He  was  treated  as  follows : 
The  ends  of  the  fractured  bone  were  carefully  placed  in  apposition, 
and  temporarily  fastened  by  lacing  the  teeth  together  with  silk 
ligatures.  The  cuspids,  being  very  firm,  were  carefully  fitted  with 
plain  bands.  Tubes  were  soldered  to  these  bands  horizontally. 
The  traction  screw  (A,  D,  and  Y)  was  now  slipped  through  the 
tubes,  and  the  bands  were  firmly  cemented  in  position  upon  the 
teeth.  The  nut  was  then  turned  upon  the  screw  until  the  fractured 
ends  of  the  bone  were  drawn  snugly  together.  This  appliance  was 
worn  without  displacement  or  further  trouble  for  twenty-one  days, 
when  it 'was  removed,  the  bone  having  become  firmly  united. 

I  may  add  that  during  the  time  the  appliance  was  worn,  so  firmly 
was  the  jaw  supported  that  the  patient  suffered  but  little  incon- 


FRACTURES    OF    THE    MAXILLA.  303 

venience,  and  after  the  third  day  partook  regularly  of  his  meals, 
using  his  jaws  freely,  but  of  course  avoiding  the  very  hard  foods. 

Final  Suggestions  on  Fractures. 

In  adjusting  bands  for  the  treatment  of  a  fracture,  carefully  con- 
sider the  direction  in  which  to  exert  the  proper  pressure  for  secur- 
ing the  jaw.  As  already  stated,  it  usually  happens  in  cases  of 
fracture  that  the  depressor  muscles  in  contracting  tend  not  only  to 
depress  the  jaw,  but  to  draw  it  backward,  especially  if  the  fracture 
be  in  the  region  of  the  last  molar.  Consequently  such  teeth  should 
be  selected  for  anchorage  as  will  direct  the  pressure  not  only  up- 
ward, but  forward,  as  in  Fig.  288. 

This  is  only  a  general  rule,  however,  and  it  is  especially  advised 
that  the  direction  of  force  necessary  in  each  case  be  carefully  con- 
sidei*ed  and  then  the  bands  and  buttons  be  adjusted  accordingly. 

Sometimes  it  is  an  advantage  to  band  more  than  one  tooth  in 
order  to  distribute  the  power  exactly  in  the  direction  necessary. 
Should  any  of  the  teeth  which  have  been  selected  for  anchorage 
show  a  tendency  to  elongation,  the  bands  should  be  shifted  to  other 
teeth  or  the  direction  of  force  be  changed.  In  but  two  instances 
have  we  noted  this  complication,  and  we  are  inclined  to  believe  that 
in  one  of  these  the  action  was  due  to  the  band  slipping  and  impin- 
ging upon  the  gum,  and  thus  probably  producing  the  same  result  as 
occurs  when  a  ligature  is  carelessly  left  about  the  tooth. 

Should  it  be  found  advisable  to  employ  the  plan  illustrated  by 
Fig.  294  or  that  shown  in  Fig.  297  in  any  case,  it  will  sometimes  be 
found  an  advantage  to  support  the  jaw  by  the  first  plan  (Fig.  285) 
for  a  few  days,  or  until  the  wounds  are  in  a  more  favorable  condi- 
tion for  taking  an  impression  or  adjusting  the  apparatus. 

Very  often  patients  receive  severe  bruises  and  internal  injuries 
at  the  time  the  fracture  is  sustained,  and  these  may  occasion  vomit- 
ing, more  or  less  violent.  Therefore,  especial  caution  should  be 
observed  that  the  securing  of  the  jaw  be  delayed  until  all  tendency 
to  nausea  has  subsided.  Be  in  no  haste,  for  no  serious  ill  effects 
are  probable  from  a  few  hours',  or  even  days',  delay  in  setting  a 
fracture.  Should  it  be  advisable  to  immediately  set  the  fracture, 
it  might  be  well  to  provide  the  attendant  with  a  pair  of  strong 
scissors  with  which  to  cut  the  ligatures  if  symptoms  of  nausea 
develop. 


304  MALOCCLUSION. 

It  should  not  require  any  argument  to  impress  the  importance 
of  extreme  cleanliness  about  the  mouth  during  the  treatment  of 
fractures.  Frequent  rinsing  of  the  mouth  with  proper  antiseptic 
solutions  should  be  insisted  upon.  If  the  fracture  be  more  or  less 
comminuted,  as  is  frequently  the  case,  suppuration  may  be  expected. 
The  plan  found  in  such  cases  most  successful  is  extra  cleansing  of 
the  wound  by  frequent  injections  of  pure,  fresh  peroxid  of  hydro- 
gen with  a  suitable  syringe.  The  patient  or  the  attendant,  with  a 
little  experience,  can  accomplish  this  quite  as  well  as  the  surgeon. 
Patience  and  persistence  in  this  line  will  soon  cause  the  necrotic 
fragments  to  be  washed  out.  Only  in  one  instance  in  the  author's 
experience  has  it  seemed  necessary  to  interfere  with  the  wound  by 
scraping  the  bone  with  instruments. 

While  the  patient  is  undergoing  treatment  his  general  health 
should  not  be  allowed  to  become  impaired.  Plenty  of  exercise  in 
the  open  air,  if  other  injuries  do  not  prevent,  should  be  insisted 
upon,  as  well  as  a  requisite  amount  of  nourishing  food ;  and  the 
surgeon  should  occasionally  inspect  the  bands  and  ligatures  to  see 
that  they  remain  in  order,  so  that  the  jaw  may  not  become  loosened 
and  admit  of  movement  of  the  fractured  ends  of  the  bone.  Should 
one  of  the  bands  be  broken,  it  should  be  replaced  as  promptly  as 
possible.  No  special  harm  will  come  from  cutting  the  ligatures, 
and  separating  the  jaws  for  the  purpose  of  replacing  it. 

In  cases  where  a  section  of  the  bone  may  show  a  tendency  to 
lean,  so  that  the  teeth  do  not  properly  occlude,  a  finger  of  metal, 
made  to  bear  against  a  tooth  in  the  leaning  section  and  soldered  to 
a  band  encircling  some  favorably-located  anchor  tooth,  will  effec- 
tually restore  the  proper  occlusion. 

In  like  manner  the  range  of  application  of  this  method  of  retain- 
ing fractures  may  be  extended  to  cases  where  fractures  occur  in  the 
body  of  the  bone  and  the  molars  are  absent.  The  edentulous  por- 
tion of  the  jaw  may  be  securely  held  in  proper  position  by  a  prop- 
made  to  bear  against  the  section  of  bone,  and  kept  in  place  by  at- 
tachment to  a  ba'nd  secured  about  one  of  the  molars  or  bicuspids  in- 
the  upper  jaw. 

The  methods  so  far  offered  will,  we  believe,  nearly  cover  the 
entire  range  of  cases  requiring  treatment.  There  still  remains, 
however,  one  distinct  class  for  consideration, — namely,  the  edentu- 
lous patient.  Fortunately,  patients  of  this  class  requiring  treat- 


FRACTURES   OF   THE    MAXILLA.  305 

ment  are  exceedingly  rare,  and  probably  the  best  plan  is  the  Gun- 
ning splint,  or,  what  is  the  same  in  principle,  attaching  together  by 
wire  or  vulcanite  the  artificial  dentures,  should  the  patient  possess 
them. 

The  cases  of  fractures  so  far  described  have  been  confined  to  the 
inferior  maxilla.  The  methods,  however,  of  securing  fixation  are 
all  more  or  less  applicable  to  the  treatment  of  fractures  in  the 
upper  jaw  as  well,  though  we  believe  the  one  first  described  is 
preferable,  for  the  reason  that  if  one  of  the  superior  maxillary 
bones  be  fractured  it  will  be  more  on  less  displaced  and  usually 
forced  downward.  After  carefully  replacing  the  pieces  the  jaws 
are  closed,  the  teeth  occluded,  and  the  pieces  supported  and  held 
upward  in  position  by  securing  the  lower  jaw  in  the  usual  way, 
with  bands,  buttons,  and  ligatures  attached  on  the  uninjured  side. 

Finally,  as  all  the  apparatus  possessing  any  special  merit  in  the 
treatment  of  fractures  of  the  maxilla  have  been  invented  by  den- 
tists, and  as  their  familiarity  with  the  parts,  their  special  knowledge 
of  mechanics,  and  the  facilities  at  their  command  fit  them  above 
all  other  surgeons  for  this  work,  we  would  recommend  that  the  dif- 
ferent dental  societies  throughout  the  country  secure  appointment 
of  competent  dentists  in  all  hospitals  for  the  treatment  of  these 
lesions,  for  to  them  this  special  line  of  surgery  justly  belongs. 


21 


INDEX. 


ABNORMAL  frenum  labium,  33,  34,  177,  178 
Age,  correct,  for  treatment,  188-191,  195 
Alveolar  process,   distribution  of,  46,  47 
plates  of,  47,  171 
structure  of,  47 

Alveolar    section    to    expedite    tooth-move- 
ment, 174 

Alveolus,  absorption  of,  57,  167,   168,  170 
arrest  in  development  of,  207,  244 
bending  of,  48,  167,  171,  227 
changes    in,    resultant    upon    tooth-move- 
ment, 57,  168-170,  207 
general  consideration  of,  45-48 
restored  to  normal  contour,  185,  186,  221 
Anchor  bands.     (See  Bands,  anchor  clamp) 

teeth.     (See  Teeth) 
Anchorage,    attachments   to   teeth   for,    141, 

149,  204,  218,  229,  244,  253 
Baker  form  of,  116,  254,  263,  279 
combination  of  occipital  and  Baker  form, 

259 

of  occipital  and  stationary,  242,  279 
of  simple  and  reciprocal,  261 
devices  for  securing,  m,  144,  204,  218,  236, 

238 
for  partial  or  complete  movement  of  teeth, 

109 

for  retention,  153,  204 

for  retrusion  of  incisors  and  cuspids,  2^5 
for  tooth-movement,    in 
gained  from  use  of  expansion  arch,  139 
general  consideration  of,  109-111,  235 
insufficient,  149 

occipital,  74,  114,  236,  242,  249,  274,  278,  279 
occlusal,  116 
reciprocal,  113,   115,  122,  123,  125,  140,  218, 

258 

reinforcement  of,  121,  124,  132,  233,  255 
simple,   in 
sources    of,    TIO 
stationary,  112,  130,  242 
Apex   of  root   of  teeth,   movement  of,   170, 

171 

Appliances.     (See  Regulating  appliances) 
Arch  B,  adjustment  of,  236,  241 


Arch  B,  bending  of,  236,  239,  253 

combined  with  traction  screw,  241,  261 
description  of,  86 

uses   of,  86,  233,  236,  244,  249,  254,   259- 
261,  277 

Arch  E.     (See  Expansion  arch) 

Arches,  dental.     (See  Dental  arches) 

Artificial  luxation,  173,  174 

BAD  advice  of  dentists,  i,  12 
Baker's  anchorage,  254 
method  of  retention,  165,   166 

of  treatment,  254,  255 
Band  driver,  95 

Band  material  F  and  H,  description  of,  81 
Bandages,  use  of,  in  fractures  of  the  max- 
illae, 287,  293,  301 
Banding  crowded  teeth,  106,  107 

cuspid  teeth,  107,  128 
Band-forming  pliers,  advantages  of,  103 

description  of,  91,  92 
Band  soldering  pliers,  description  of,  91 

uses  of,   102,   103 

Bands,    anchor   clamp,    adjustment    of,    107, 
108,  142,  288,  289 

with  cement,  108,  130 
description  of  No.  i,  82 
No.  2,  82,  223 
No.  3,  82 
No.  4,  82 
X,  82,  204,  218 
D,   82,    141,   204,   218,   239 
for  securing  ends  of  arches,  141,  143 
making  attachments  to,  109 
mistakes  in  adjustment  of,   107,   108 
fracture,  288,  290,  292-295 

adjustment  of,  288 
inspection  of  retaining,  160,  191 
Magill's,  73 
plain,    author's    method    of    constructing, 

IOI,    103 

correct  method  of  setting,  73,  106 
Desirabode,  72 
Evans,   72 
Farrar,   72 

307 


3o8 


INDEX. 


Bands,   faulty    methods   of   making,   72,   73, 

100,  101 
Fuller,  72 

placing  of  spurs  to,  134 
soldered  attachments  to,  104,  105 
to  loosen,   106 

united  for  retention,  153,  159,  211,  220 
with  spurs,  for  retention,   152,   153,   156- 
158,  207,   209,   211,   212,   215,   219,   220, 
223,  228,  230,  232,  254 
practical  use  of,   137,   138,  204-206,  211, 

212,     2l8,     222,     224,    226,     229,     231,     233, 

238,  264,  266,  271,  272 
Schange's,  71,  7- 
Beauty,  characteristics  of,  16 
definition  of,  16 
types  of,  17,  18,  19 

Bicuspid   teeth,   attachments   to,   for  eleva- 
tion,  244-246 
extraction  of,  201,  202,  235,  261,  264,  266, 

276 

inclination  of,  230 
occlusion  of,  8 
retention  of,  158,  161,  228 
rotation  of,  132,  160,  206 
Biting  lips.     (See  Lips) 
Blow-pipe,  Herapath,  95 
Bone,  surgical  removal  of,  174,  242,  253 
Bracket  table,  96,  97 
Brass  wire  for  ligatures,  75 
Bryan,  Dr.,  artificial  luxation,  173,  174 
Buccal  movement  of  teeth,  137,  166,  171 
tissue-changes  incident  to,  169,  171 

CASE,  Dr.  C.  S.,  appliances,  109,  245 
Cases,  practical,  corrected,  197,  199,  207,  208, 
210,    211,    213,    214,    219-221,    223,    224, 
228,  232,  243,  249-251,  254,  256,  265,  273 
study  of,  69 

Causes  of  malocclusion:  Habits,  28 
inheritance,  23 

loss  of  permanent  teeth,  26-28 
premature  loss   of  deciduous  teeth,  24, 

214 
prolonged  retention  of  deciduous  teeth, 

25 

supernumerary  teeth,  28 
tardy  eruption  of  permanent  teeth,  27 
Cells  of  peridental  membrane,  49 
Cement,  celluloid,  62 
Cementing  plain  bands,  106 

clamp  bands,  108-130 
Central  incisors.     (See  Incisors) 
Changes,  alveolar,  incident  to  tooth  move- 
ment, 57,  166,  167 

subsequent  to  tooth  movement,  184-188 
Chin  retractor,  adjustment  of,  270,  271 
description  of,  88 


Chin  retractor,  value  of,  270 
Clamp  bands.    (See  Bands) 
Class  I,  13,  186 
average  case,  36 
described,  37,  197 
extraction  in,  198 
general  consideration  of,  193,  194 
illustrated,  36 

percentage  predominance  of,  44,  197 
retention   of   practical   cases.    (See   Re- 
tention) 

treatment    of    practical    cases,    197,    202, 
208,  211-215,  221,  223,  225,  228,  230,  232, 
233 
Class  II,  13,  30,  234 

distinguishing    characteristics    of,    37, 

234 

general  consideration  of,  37,  234 
Division  i,  13,  22,  30,  161,  162,  188 

described  and  illustrated,  37,  38,  234- 

236 

retention  of.    (See  Retention) 
treatment,  first  plan,  235-237,  241,  242 
second  plan,  247,  252 
Baker  method,  254 
of    malocclusion    of    lower    teeth, 

243,  245,  246,  255 
Subdivision,  described  and  illustrated, 

38,  40,  261 
retention  of,  263 
treatment  of,  261,  262 

Baker  method,  263 
Division  2,  described  and  illustrated,  39, 

40,  263,  264 
retention  of,  266 
treatment  of,  first  plan,  264 

second  plan,  264,  265 
Subdivision,  described  and  illustrated, 

40,  266,  267 
retention  of,  268 
treatment  of,  266 
Class  III,  distinguishing  characteristics  of, 

40,  268 
Division,  described  and   illustrated,  41, 

268,  269 

retention  of,  273,  274 
treatment    of,    combination    of   plans, 

272,  274,  276 
first  plan,  269,  270 
second  plan,  269-271 
third  plan,  269,  275,  276 
fourth  plan,  270,  276 
Subdivision,     distinguishing    character- 
istics of,  279 

general  description  of,  279 
retention  of,  279 
treatment  of,  279 
Classification  of  malocclusion,  34 


INDEX. 


.Coffin,   Dr.    Seldon,   introduction   of  piano- 
wire,  74 
Combinations     of     regulating     appliances. 

(See  Regulating  appliances) 
Contraction  arch  B.     (See  Arch  B) 
Cuspid  teeth,  banding,  106,  107 
elevation  of,  206,  267 
extraction  of,  201 
forcing  eruption  of,  149,  272,  273 
labial  movement  of,  120,  121,  123,  131 
lingual  movement  of,  131 
mesio-labial  movement  of,  222 
missing  permanent,   194 
occlusion  of,  8 

premature  loss  of  deciduous,  25,  214,  221 
retention  of,  138,   162,   164,   165,  207,  209, 

212,  219,  220,  228 
retraction  of,  127,  131,  146,  167,  241,  264, 

266 

rotation  of,  123,  131,  204,  206,  219 
Cusps,   importance  of  interdigitation  of,  9, 


DEFINITIONS:  Line  of  harmony,  16 

of  occlusion,  13 
malocclusion,  6 
orthodontia,  6 
retention,  153 
Dental  arches: 

both  lateral  halves  of  upper,  in  lingual 

occlusion,  187,  225 
contraction  of  lower,  226,  227 

of  upper,  235,  236,  241,  242,  247,  249 
development  of,  25,  26 
effect  of  diminished  size  of  lower,  n,  12, 

25,  151,  195,  204,  218,  224 
of  diminished   size  of  upper,  28,   195, 

204 
equal  importance  of  lateral  halves  of,  36, 

42 
establishment   of  harmony   in    sizes   of, 

152,  194,  261,  264 

expansion  of  lower,  167,  204,  208,  213,  215 
of   upper,    167,   204,   208,   213,   215,   226, 

229,  249,  253 
importance    of    harmony    in    sizes    and 

relations  of,  9,  26,  218 
interdependence  of,  9,  10 
lengthening  of  lateral  halves  of,  24,  144, 

146,  222-224 
.    lower,  importance  of,  9,  243 

one  lateral  half  of  upper  in  lingual  oc- 
clusion, 229 

relations  of,  in  Class  I,  37,  197 
in  Class  II,  Division  i,  37,  38,  234 

Subdivision,  38,  40,  261 
Division  2,  39,  40,  263 
Subdivision,  40,  266 


309 

Dental    arches,   relations  of,  in  Class  III, 
41,  42,  268 

Subdivision,   42,   43,  279 
retention,  223,  224,  230 
of  lower,  backward,  273 
of  lower,  forward,  162-164 
widening  of,  138,  144,  148,  167,  213,  226, 

230,  239,  249 
Depression  of  teeth,  55 

tissue-changes  incident  to,  168 
Desirabode  bands,  72 

modification  of  expansion  arch,  136 
Devices  for  overcoming  thumb-sucking,  30, 

164 

for  retention.     (See  Retention) 
for  securing  anchorage.     (See  Anchorage) 
for    treatment    of    fractures.    (See    Frac- 
tures of  the  maxillae) 
Diagnosis,  importance  of  correct,  34,  43 
of  line  of  harmony  in,  17 
of  line  of  occlusion  in,  13,  14 
points  to  be  considered  in,  34,  35 
Distal  movement  of  teeth,  127,  131,  146,  147, 

166,  218,  224,  264 
tissue-changes  incident  to,  169 
Disuse  of  teeth,  31 
Dwindle,  72 

EARLY  interference,  importance  of,  12 
Elevation  of  bicuspids,  244-246 
attachments  for,  138 
Dr.  Case,  245 
of  cuspids,  149,  206,  267 
of  incisors,   233 
of  molars,  244-246 

of  teeth,  tissue-changes  incident  to,  168 
Eruption,  forcing,  of  cuspid,  149,  272,  273 

tardy,  of  permanent  teeth,  28 
Evans,  Thos.,  bands,  72 
Excision  of  lower  jaw,  297 
Expansion  arch,  author's  improvements  qf. 

8S,    137.   140 

bending  of,  205,  218,  231 
combined   with  bands,   spurs,   and  liga- 
tures,  137,  204,  205,  207-209,  211,  213, 

2l8,     222,     224,     226,     229,     23O,     231,     233, 

244,  246,  260,  261,  264,  266,  271 
with  traction  screw,  143,  264,  266 
description  of,  85,  139 
direction  and  distribution  of  force  from, 

138,  140,  219,  226 
directions  for  adjusting,   133 
early  forms  of,  72,  135,  136 
Fauchard's,  71,  134 
Fox's,  136 
Harris's,  136 
improper  uses  of,  140 
reinforcement  of,   142,  226,  229 


3io 


INDEX. 


Expansion  arch,  Schange's,  72,  136 

use  of,  85,   137,   138 

Extraction,  evil  effects  of,   i,  24-27,  214,  22 
224 

general  consideration  of,  198,  200-202 

in  Class  I,  198,  199 

in  Class  II,  235,  261,  264,  266 

in  Class  III,  276,  279 

of  bicuspids,  201,  235.  261,  264,  266,  276 

of  cuspids,  201 

of  incisors,  27,  201 

of  molars,  25,  26,  201,  224 

premature,   of   deciduous   teeth,  23-25,  214, 

222 

FACIAL  art,   15 

Facial  line  of  harmony.     (See  Line  of  har- 
mony) 
Facial  lines,  ideal,   17,  18,  196 

improvement    of,    196,   208,   222,   245,   2^9, 

256,   258,   266,   277 
in  Class  I,  204,  225 

in  Class  II,  37,  40,  234,  248,  255,  257,  266 
in  Class  III,  269,  276 
marring  of,   17,   18,   196 
Farrar's  band,  72 

Fauchard's  expansion  arch,  71,  134 
Fibers  of  peridental  membrane.     (See  Peri- 
dental  membrane) 
Fox's  expansion  arch,  136 
Fracture   bands,   288 

adjustment   of,   288,   289 

Fractures  of  the  maxillae,  bandages  for  treat- 
ment of,  288,  290,  292-295 
bands  for  treatment  of,  288,  290,  292-295 
final  suggestions,  303-3°$ 
general  consideration  of,  285,  286 
Hamilton  on,  285 
interdental  splints  for  treatment  of,  288, 

300,  301 

location  of,   285,  286 
methods  of  fixation  in,  286-288,  293,  294, 

299,  302 

of  reduction  in,  285,  288,  293,  294 
occlusion  of  teeth  as  a  guide  in  setting, 

286,  288 
treatment  of  practical  cases  of,  289,  291, 

292,  294,  295,  299,  300 

wiring  ends  of  bone  together  in,  287,  298 
Frenum  labium,  abnormal,  33,  34,  177 
method  of  operating  on,   178 
section  of,   177 
Fuller,  plain  bands,  72 

GAG,  obsolete  appliance,  213 

Gaines's  screw,  72 

German  silver,  composition  of,  79,   101 

introduction  of,  75 

use  of,  79 


German  silver,  value  of,  79,  80 
Gold  for  the  construction  of  regulating  ap- 
pliances, 80,  81 
Guilford's  bands  for  retention,  153 

HABITS,  29 

Hamilton  on  fractures  of  the  maxillae,  285 
Harris's   expansion  arch,   136 
Head-gear,  adjustment  of,  87,  88,  237,  240 

description    of,    88 

introduction  of,  74 

Kingsley's,  74 

pressure  from,  279 

wearing  of,  239,  240,  271,  273,  277-279 
Heath,   Sir  Christopher,  use  of  Interdental 

splint,  300 

Herapath  blower,  description  of,  95 
Hippocrates'  plan  of  fixation  of  fracture  of 
the  maxillae,  298 

IDEALS  in  facial  lines,  16-18,  194 

in  occlusion,  7,  8,   194 
Impression  trays,  59,  60 
Impressions,  author's  method  of  taking,  59 
plaster,    58 
plastics  for,  58 
removing,  61,  63 
from   arches  with   spaces   of  lost  teeth, 

63,  6.1 
steps  in  taking  lower,  63 

upper,   59 
united,  62,  63 
uniting,    61,    62 
varnishing,  (•* 
Incisors,   central,  labial   movement  of,    123, 

206,  208,  222,  229,  276 
retention  of,   161,   162,   164,   166,  207,  212, 

219,  220,  228,  230,  271 
rotation  of,  double,  127,  149,  271 

single,   123,  125,  126,  253 
depression   of,  249 
distal  movement  of,  236 
elevation  of,  233 
inclination  of,  40,  41,  181,  187,  198,  202,  206, 

230 
labial  movement  of,  170,  204,  206,  208,  212- 

214,  217 

lateral,  distal  movement  of,  237 
extraction  of,  27,  201 
labial  movement  of,  122,  125,  133,  146 
lingual   movement  of,   123 
missing,    indicated    by    skiagraph,    193, 

194 
retention  of,   161,  162,   164,  166,  207,  212, 

219,  220,  228,  230 
rotation  of,  124,  125,  145,  146 
torso-labial  movement  of,  145,  229 
lingual    movement    of,    170,    241,    242,    253, 
261,  262,  279 


INDEX. 


Incisors,   movement   of,   en   masse,  217,  218, 

226 

occlusion  of,  7,  8 
protrusion  of  deciduous,  251 

of  upper,  25,  27,  161,  244,  252 
retention  of,  157,  158,  161,  162,  164,  166,  228 
retrusion  of,  237,  239,  241 
shortening  lower,  243-246 
Inclined   occlusal   planes,   establishment   of 
harmony  between,  4,  g,   194,  261,  266 
final  adjustment  of,  158,  194 
influence  of,  8,  10,  n,  13,  194 
mutual  support  of,  9,  236 
permanent  retention  of,   194 
Inherited  tendencies  to  malocclusion,  23 
Inspection  of  ligatures  and  attachments,  241 

of  retained  teeth,  191 
Interdental  splint  for  treatment  of  fractures 

of  the  maxilla,  288,  296,  300 
Heath's  form   of,  300 
Kingsley's  form  of,  300 
Martindale's   form   of,  300 
Irregularities  of  the  teeth,  5 

JACK-SCREW,  early  forms  of,  70,  73 
description  of  author's,  E  and  J,  83 
in  combination  with  levers,  144,  145,  213 

with  traction  screw,  146 
in  combinations,  121-123,  J47>  207,  293 
in  movement  of  cuspids,  120,  121,  123 

of  incisors,  122,  123,  276 
invention  of  Dwindle,  73 
methods  of  securing  point,  119 
sheath,  118,  119 
Jaws:  double  resection  of  lower  jaw,  179-182, 

183,    184,  268 
establishment  of  harmony  in  relations  of 

jaws,   195,  243,  250,  254 
excision  of  lower  jaw,  297 
fractures  of  jaws.     (See  Fractures) 
method  of  performing  double  resection  of 

lower  jaw,  180,  182 
modification  of  form  of  lower  jaw,  195 

of  upper  jaw,   196 
position  of  lower  jaw,   195,  247,  253,  265, 

270,  272,  274,   275 
movement   of  jaw  from   distal   occlusion, 

21,  247,  248,  253,  254,  256 
from  mesial  occlusion,  272,  274 
overdevelopment  of  jaws,  268 
relations  of  jaws  in  Class  I,  37,  197 
in  Class  II,  37-40,  234,  261,  263,  266 
in  Class  III,  40,  268,  279 
retention  of  lower  jaw  backward,  273 
forward,  162-164,  250,  253 

KINGSLEY'S  head-gear,  74 
modification  of  retaining  plate,  166 
splint  for  treatment  of  fractures,  300 


LABIAL  movement  of  teeth,  55,  137 
of  cuspids,  119,  121,  123,  131,  206,  208 
of   incisors,    122,    123,    125,    133,    I46,    167, 
170,  204,  206,  208,  212-214,  217,  222,  229, 
276 

tissue-changes  incident  to,  169,  170 
Lateral  incisors.     (See  Incisors) 
Lee  and   Bennett  traction  screw,  73 
Levers  L,  combinations  of,  124-127,  148 

with  jack-screws,  144,  145,  213 
description  of,  84 
for  rotation,   124-127,  146 
to    reinforce    expansion   arch,    142,   226, 

229 

various   sizes   of,    123 
Ligatures,  adjustment  of,  137,  232 
brass   wire,   75,   89 
floss   silk,   89,   90 
for  rotation,  127,  149 
forms  of,  89,  90 
inspection  of,  241 

rubber,  87,  233,  236,  238,  239,  253,  259 
tightening  of,  127,  138,  206,  268 
use  of,  in  treatment  of  malocclusion,  137, 

138,      204-206,      211,      212,      222,      224,      226, 

229.  231.  233,  249,  264,  266,  271,  272 
in   treatment   of   fractures,   289,    293-296, 

298 

value  of  wire,  122,  137,  219 
Line  of  harmony,  application  of,  17-20 
definition  of,  16,  17 
importance  of,  17 
location  of,  17 
of    occlusion,     adjustment    of    malposed 

teeth  to,  194,  197,  199,  219,  220 
definition  of,  13 
form  of,  13 
importance  of,  13 
location  of,  13 

Lingual  movement  of  teeth,  55 
of   cuspids,    131,  204 
of  incisors,  123,  170,  171 
of  molars,  171 

tissue-changes  incident  to,   169,  170 
occlusion  of  lateral  halves  of  upper  arch, 

17,  225 

of  one  lateral  half  of  upper  arch,  229 
Lips,  abnormal  function  of,   n,  25,  224,  234 
biting  lower,  29,  30,  165 
development  of,   19 
influence  of,   in   malocclusion,    n,   25,  27, 

30,  234 

normal  function  of,  10,  250,  264 
Loss  of  deciduous  teeth.    (See  Extraction) 
of  permanent  teeth.     (See  Extraction) 

MAGILL'S  band,  73 
Mallet,  95 


312 


INDEX. 


Malocclusion,  age  for  treatment  of,  188-191,  | 

i9S 

advantages  of  early  treatment  of,  189,  190 
causes  of.     (See  Causes) 
classification  of,  34 
Class  I  of.     (See  Class  I) 
Class  II  of.     (See  Class  II) 
Class  III  of.     (See  Class  III) 
correction  of,  generally  considered,  6 
definition  of,  6 
development  of,  n,  24-33,  224 
diagnosis  of  cases  of.     (See  Diagnosis) 
effects  of,  3 
forces  governing,  n,  12 
objects    to    accomplish    in    treatment    of, 

194 

positions  of,  14,  35 
buccal  occlusion,  14,  25,  197 
distal  occlusion,  14,  27,  37,  162,  224,  234, 

247,  249,  252,  253,  261,  264,  266 
disto-torso-occlusion,  218 
infra-occlusion,  14,  31,  210,  232,  233,  244 
labial  occlusion,  14,  147,  203,  247 
lingual  occlusion,   14,   125,   147,   150,   197, 

203,  211,  212,  216,  225,  229,  243,  253 
mesial  occlusion,  14,  40,  42,  268,  279 
supra-occlusion,  14,  31,  244,  253 
torso-occlusion,  14,  123,  194,  211,  216,  243, 

271 

torso-labial  occlusion,  225 
torso-lingual  occlusion,  225,  229 
possible  class  of,  42 
study  of  cases  of,  69 
table  of  classes  of,  44 
time  required  for  treatment  of,  191,  192 
Martindale's  interdental  splint,  300 
Maxilla,  double  resection  of  lower,  179-184 
excision  of  lower,  297 
fractures  of.     (See  Fractures) 
Mesial  movement  of  teeth,  166-212 

tissue-changes  incident  to,  169 
Mesio-labial  movement  of  teeth,  222 
Model  cabinet,  65,  66 
Models,  general  consideration  of,  57,  58 
pouring,  64 
repairing,  64 
separating,  64 

"study,"  65,  205,  206,  212,  217 
value  of  accurate,  57,  58,  65 
Molars,  attachments  for  elevation  of,  244-246 
extraction  of,  24,  26,  27,  201,  224 
mesio-labial  movement  of,  222 
occlusion  of,  8,  224 
pitted,  232 

retention  of,  158,  160,  161,  225,  228 
rotation   of,   231 

used  as  anchorage,  204,  209,  212,  218,  226, 
233 


Mouth-breathing,  effect  of,  2p,  32,  37,  151 

general  consideration  of,  234 
Movements  of  teeth,  buccal,  137,  166 
collectively,   117,   138,  204 
combinations  of,  166,  167 
depression  in,  55,  166,  246 
distal,  127,  131,  146,  147,  166,  218,  224,  264 
elevation  in,  55,  149,  166,  206,  233,  244-246, 

267,  272. 

en  masse,  217,  218,  226 
labial,  55,   119-123,  125,  133,  137,  146,  147, 

166,  206,  208,  212,  217,  229,  264,  266 
labio-buccal,  218 
lingual,    ss,    123,    131,    147,    166,   231,   236, 

237,  242,  249,  252,  253 
mesial,  166,  212 
rotation  in,  55,  106,  123-127,  131,  132,  145, 

146,  148,  166,  205,  206,  208,  209,  219,  226, 

229,  231,  253,  271 
singly,   147,   166 

tissue-changes  incident  to,  166-172 
torso-labial,   145 
Muscles,  influence  of,  5,  10,  n,  13,  25,  211, 

214,  234,  247 

NASAL  obstructions,  effect  of,  32,  37,  234 

necessity  for  overcoming,  32 
Nomenclature,  14,  20 

OCCLUSAL    planes.    (See    Inclined    occlusal 

planes) 
Occlusion,  basis  of  science  of  orthodontia,  6 

buccal,  14,  25,  197 

comprehension  of,  5 

details  of,  6,  7,  8 

distal,  14,  27,  37,  162,  224,  234,  247,  249,  252, 
253,  261,  264,  266 

establishment  of  normal,  6,   194,   195,  235, 
247,  264,  273 

for  retention,  124,  194,  213,  273 

forces  governing  normal,  9 

ideal,  7,  8,  194 

importance  of  perfect,  5 

improved,   195,  235,  264 

infra-,  14,  31,  210,  232,  233,  244 

key  to  normal,  6 

labial,    14,   147,  203,  247 

line  of.     (See  Line  of  occlusion) 

lingual,  14,  125,  147,  150,  197,  203,  211,  212, 
216,  225,  229,  243,  253 

mesial,  14,  40,  42,  268,  279 

supra-,  14,  31,  244,  253 

torso-,  14,  123,  194,  211,  216,  243,  271 

torso-labial,  225 

torso-lingual,  225,  229 

Orthodontia  as  related  to  comparative  anat- 
omy, 6,  280 

as  related  to  rhinology,  235,  280 

definition  of,  6 


INDEX. 


313 


Orthodontia,  final  suggestions  on,  281-284 
growth  of,  i,  3 
importance  of,  2 

PERID  XNTAL     membrane,     arrangement     of 

fibers  of,  49-52 
attachment  of  fibers  of,  52 
changes  in,  incident  to  tooth-movement, 

57,   167,   168 
functions  of,  48,  49 
genera]  consideration  of,  48,  219 
pathological  conditions  of,  53,  151 
resection  of  fibers  of,  175-177 
structure  of,  246 
Periosteum,   48 

Photographs  of  patients,  65,  66,  192 
Piano-wire,   Coffin's   introduction  of,  74 
Plates,  vulcanite,  161,  165,  215,  228,  230 
for  retention,  160,  161 
Kingsley's  modification  of,  166 
old  forms  of,  i,  77,  78,  in 
Pliers,  flat-beaked,  95 
plain,  91 

regulating,  94,  223,  225 
Profile,  imperfect,  18,  19 

perfect,  16,  17 
Prognathism,  20 
Pulp  of  teeth,  25,  171,  172 

REGULATING  appliances,  author's: 
See  Arch  B 

Band  material 
Bands,  clamp 
Chin  retractor 
Expansion  arch 
Head-gear 
Jack-screw  E  and  J 
Levers  L 
Retaining  tubes  R 
Retaining  wire  G 
Traction  bar  A 
Traction  screw  A,  D,  and  Y 
Wrench 
combinations  for  buccal  movement,  137, 

166 

for  contraction,  227 
for  depression,  55,  166,  246 
for  elevation,  55,  149,  166,  206,  233,  244- 

246,  267,  272 
for  expansion,  205,  208,  209,  212,  217, 

226,  229,  231,  249,  253 
for  labial   movement,   55,    120,    121-123, 
125,   131,    133,   137,   146,   147,    166,  205, 
206,  208,  212,  213,  217,  229,  264,  266 
for  lengthening  arch,   144 
for  lingual  movement,  55,  131,  147,  166, 

*3i»  236,  237,  242,  249,  252,  253 
for    mesial    movement,    166 


Regulating  appliances,  combinations  for   re- 
traction of  cuspids,  127, 131,  144,  146, 167, 

241,  242,  261,  264,  266 

for  retrusion  of  incisors,  236,  239,  241, 

242,  249,  252,  253,  261-263 

for  rotation,  55,   106,   123-126,   127,  131, 
132,   145,   146,   148,   166,  205,  206,  208, 
209,  219,  226,  229,  231,  253,  271 
for  treatment  of  Class  I,  204,  205,  207- 
209,  212,  213,  217,  218,  222,  224,  226, 
227,  229,  231,  236,  239 
of  Class  II,  Division  i,  236,  237,  241, 
242,  244,  252,  253,  254,  255,  259 
Division  i,  Subdivision,  261 
Division  2,  264,  265 
Division  2,  Subdivision,  266 
of  Class  III,  Divisior,  270,  271,  276, 

278 

Subdivision,  279 

for      various      movements      simulta- 
neously,  138,  204,  205,  207,  209,  212, 

213,  2l8,  222,  224,  226,  230,  231,  236, 
237,  242,  246,  252,  253,  26l,  262,  264- 
266,  271,  272,  277 

for  widening  the  arch,  144 
miscellaneous,  144-147,  227 
construction  of,  72,  74,  75,  79 
definition  of,  67 
functions  of,  117 
general  consideration  of,  67 
history  of,  70 

jack-screw,  early  forms  of,  70,  73 
Patrick  regulator,  70 
piano-wire,        introduction        of.      (See 

Levers) 
Schange's  clamp  band,  71,  72 

screw,  72 

special  designs  in,  67-69 
standard  forms  of,  68,  69 
systematized,  68,  75,  117 
traction  screw,  73,  74 
tubes,  74 
vulcanite,  74 

Regulating  pliers,  94,  223,  225 
Retaining  bands,  inspection  of,  160,  191 
Retaining  devices,   illustrated,    i54-i59t   161- 

165,   199 

materials  for  construction  of,  152-165 
tubes  R,  description  of,  74,  83 

use  of,  123,  125,  132,  157,  223,  232,  253 
wire  G,  description  of,  82,  83 

uses  of,  82,  83,  104,  123,  126,  132,  157, 
207,  209,  219,  223,  228,  230,  232,  238, 

253 

Retention,  anchorage  for,  153,  204 
anticipation  of,  105,  120,  121 
application  of  principles  of,  153 
automatic,  88,  238 


INDEX. 


Retention,  Baker  method  of,  165,  166,  261 
by  occlusion,  124,  194,  213 
definition  of,   153 

general  consideration  of,  150,  152,  161 
general  rule  for,  151 
of  bicuspids,   158,  160,  161,  228 
of  Class  I,  207,  209,  211-213,  215,  219,  220, 

225,  228,  230,  232 
of  Class  II,  161-165,  249.  2S°»  253,  254,  263, 

266,  268 

of  Class  III,  273,  279 

of  cuspids,  158,   162,  164,   165,  207,  209,  212 
of  dental  arches,  lower,  162-164,  227 

upper,  161,  207,  215,  228 
of  incisors,  156,  161,  162,  164,  166,  207,  212 
of  lower  jaw  backward,  274 
of  lower  jaw  forward,  162,  163,  250,  253 
of  molars,  158,  160 
of  space  of  missing  teeth,  25,  154,  155,  214, 

215,  223,  225 
of  teeth  after  section  of  frenum  labium, 

1/8,    179 

of  teeth  collectively,  157,  159 
principles  of,  153 
temporary,  127,  149,  152 
time  required  for,  30,  150 
Retraction    of    cuspids,    127,    131,    146,    167, 

241,  264 

Retrusion  of  incisors,  237,  239,  241 
Roots  of  teeth,  adjustment  of,  170 
Rotation  by  means  of  arch  B  combinations, 

253 

by    means    of    expansion    arch    combina- 
tions,  138,  205,  206,  208,  209,  219,  226, 

229,  231 

by  means  of  jack-screw,  123,  145 
by  means  of  lever,  124-127,  145,  146 
by  means  of  ligature,  127,  149 
by  means  of  traction  screw,  131,  132 
double,  149,  271 
of  bicuspids,   132,  206 
of  cuspids,  125,   131,  204,  206,  219 
of  incisors,   central,   123,    125-127,   149,   271 
of  incisors,  lateral,  124,  125,  145,  146 
of  molars,  231 
movement  of,  55 
tissue-changes   incident  to,    168 
Rubber  in  regulating,  introduction  of,  74 
wedges,  practical  use  of,  90,  125,  231,  266, 

272,  273 

SCHANGE'S  anchorage  of  arch,  136 

bands,  71,  72 

expansion  arch,  72 

screw,  72 

Scissors,  description  of,  94 
Skiagraphs,  illustrated,   193 

value  of,  in  study  of  cases,  193,  194 


Soft  soldering,  author's  method  of,  98,  99 

Solder,  kind  of,  to  use,  98,  102 

Soldered  attachments  to  clamp  bands,  97 

to  plain  bands,  104,  105 
spurs  to  arch  B,  98 

to  expansion  arch,  99 
Soldering,  author's  method,  96-98 
I   proper  flame  for,  95,  96,  102.   104,  259 
table  for,  96,  97 
technique  of.  280 
Soldering  fluid,  99 
pliers,   description  of,  91 

use  of,  102,  103 
tubes,  96,  105 

Spurs  attached  to  arches,  98,  259 
to  plain  bands,  104,  105 
directions  for  making,  98,  99 
use  of,   153,   154,  205 
Staples  attached  to  plain  bands,  104,  105 
Study  models,  65,  205,  206,  212,  217 

of  cases,  193,  194,  197 
Suggestions,  final,  on  fractures,  303-305 

on  orthodontia,  281-284 
for  teachers,  280 
Supernumerary  teeth,  28,  29 
Surgery:    Alveolar  section,  174 
double  resection  of  lower  maxilla,  179^84, 

268 
in  tooth-movement,  conservative,  173,  242, 

2S3 

operative,   173 
section  of  frenum  labium,   177,  178 

of  fibers  of  peridental  membrane,  175-177 
Surgical  removal  of  bone,  174,  242,  253 

TABULATED    classification    of    malocclusion, 

44 

Teachers,  suggestions  for,  280 
Teeth,  anchor,  125,  128,  141,  145,  204,  212,  229, 

233 
attachments   to,    for   anchorage,    141,    149, 

204,  218,  229,  253 

deciduous,  pitted  for  imbedding  spurs,  25 
premature  loss  of,  24,  25,  214,  222 
prolonged  retention  of,  25 
effects  of  disuse  of,  31 
extraction    of.     (See    Extraction) 
final  adjustment  in  occlusion,  210 

of  apices  of  roots,  170,  171 
grinding   of,   243 
interdependence  of,  26 
movement  of,  by  lengthening  wire,  223 
mutual  support  of,  8 
occlusion  of,  8 
permanent,  loss  of,  26 
tardy  eruption  of,  28 
pulp  of,  25 
retention  of.     (See  Retention) 


INDEX. 


315 


Teeth,  seven  movements  of,  35,  166 
shapes  of,  5,  9,  n 
sockets  of,  47 
supernumerary,  28,  29 
torso-labial  movement  of,  229 
Thumb-sucking,  effects  of,  29 
Tongue-sucking,  effects  of,  29,  31 
Tools,  author's  selection: 
See  Herapath  blower 
Mallet 
Pliers 
Scissors 
Wire  cutters 

Tooth  movement,  alveolar  section  to  expe- 
dite, 174 
immediate,  173 

physiological  laws  governing,  192,  241 
tissue-changes  incident  to,  166,   167-172 

subsequent  to,  184-188 
Traction  bar  A,  adjustment  of,  86,  87 
description  of,  86 
uses  of,  86,  236 

screw   A,   D,   and   Y,   adjustment   of,  84, 
128-130 
combinations  of,  127,  132,  133,  143,  146, 

241,  261,  264,  266,  276,  277,  302 
description  of,  83 
operated    on    lingual    side    of    dental 

arch,  131,  146 
Lee  and  Bennett's,  73 

Treatment,  advantages  of  early,  189,  190,  268 
correct  age  for,  188,  189, 
general  consideration  of,  192,  197 
rule  governing,  191 


Treatment,  objects  of,  194,  197,  247,  261,  264 
of  cases,  Class  I,  197,  202,  208,  an,  213-215, 

221,  223,  225,  228,  230,  232,  233 
Class  II,  235,  247,  252,  263-266 
Class  III,  269-271,  274,  276 
of  fractures  of  the   maxilla.    (See   Frac- 
tures) 

requirements  of,  197 
time  required  for,  191,  192,  242 
Tubes,   introduction   of,  74 
Tubes  R  attached  to  plain  bands,  104,  105 
Tucker's  introduction  of  rubber  in  regulat- 
ing, 74 

VARNISHES,  64 
Varnishing  impressions,  64 
Vulcanite  for  construction  of  regulating  ap- 
pliances, 74,  79 
plates,  adjustment  of,  160,  161 
Baker's  modification  of,  165 
for  retention  of  lower  arch,  161,  165 
of  protruding  upper  incisors,  161,  165 
of  upper  arches,  161,  163,  215,  228,  230, 
249 

WIRE,  brass,  for  ligatures,  75 

piano,  74 

pinching,  to  lengthen,  253 
Wire-cutters,  93 

Wiring  ends  of  bone  in  fractures,  287,  298 
Wrench,  description  of  author's,  85 


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